QME location limit
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-10 offices
% of causation for psych injuries
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-Jan 1, 1990 - July 17, 1993 - at least 10% of injury must be due to actual
events of emmployment
-July 17, 1993+ actual events of employment must be predominant (>50%)
cause of injury
-Unless due to sig. violent act, then 35-40% of all causation
,Additional QME office costs
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-$100/year per office
Self referrals/Cross referrals
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-Tx phys may not self-refer and are required to include a declaration that
they're not violating this rule ON ALL BILLS/QME reports
-Not allowed:
-outside referrals for svcs in which Dr has financial interest;
-cross arrangement whose purpose is to ensure referrals;
-compensation for referrals
Expedited review
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-UR conducted when IW faces imminent/serious threat to health or normal
timeframe to make decision would be detrimental.
-Does not exceed 72 hrs
Excluded injuries
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, 1. Caused by employees use of ETOH or drugs
2. Intentionally self-inflicted
3. Suicide if willful and deliberate
4. Injuries resulting from altercations in which the injured employee is the
initial physical aggressor
5. Injuries resulting from employee's conviction of a felony
6. Injuries resulting from off-duty recreational activities
7. Psych injury claimed after notice of termination (unless certain conditions
exist)
Injury (work comp)
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-Injury or disease arising out of employment
-Injury caused by tx of an injury arising out of employment
-Any side effect from preventative healthcare provided by employer
-Must cause disability or needs medical tx
-Must lose work time/impact ability to work
Physicians claims process
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-Primary tx phys: manages med. care and tx; IW can only have 1 PTP at a
time, and PTP can refer to consulting phys at employer expense
-Employer can have IW examined by phys of their choice
-Secondary tx phys: not primarily responsible for med tx, can examine and
treat IW
-PTP, secondary phys, QME/AME, consulting phys
, Delayed recovery
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-DR: does not improve in timely manner
P&S dates
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-If before 1/1/05: 1997 PDRS, rate on work restrictions
-If after 1/1/05: AMA Guides 5th ed., rate on impairment
Means of communication
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-All communication must be through letter/mail
Medical Unit
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-Executive med director; performs services related to delivery of med
benefits
-Est. policy and guidelines for tx and eval of IW
-Appoints QMEs; investigates complaints on QMEs
Give this one a try later!
-10 offices
% of causation for psych injuries
Give this one a try later!
-Jan 1, 1990 - July 17, 1993 - at least 10% of injury must be due to actual
events of emmployment
-July 17, 1993+ actual events of employment must be predominant (>50%)
cause of injury
-Unless due to sig. violent act, then 35-40% of all causation
,Additional QME office costs
Give this one a try later!
-$100/year per office
Self referrals/Cross referrals
Give this one a try later!
-Tx phys may not self-refer and are required to include a declaration that
they're not violating this rule ON ALL BILLS/QME reports
-Not allowed:
-outside referrals for svcs in which Dr has financial interest;
-cross arrangement whose purpose is to ensure referrals;
-compensation for referrals
Expedited review
Give this one a try later!
-UR conducted when IW faces imminent/serious threat to health or normal
timeframe to make decision would be detrimental.
-Does not exceed 72 hrs
Excluded injuries
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, 1. Caused by employees use of ETOH or drugs
2. Intentionally self-inflicted
3. Suicide if willful and deliberate
4. Injuries resulting from altercations in which the injured employee is the
initial physical aggressor
5. Injuries resulting from employee's conviction of a felony
6. Injuries resulting from off-duty recreational activities
7. Psych injury claimed after notice of termination (unless certain conditions
exist)
Injury (work comp)
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-Injury or disease arising out of employment
-Injury caused by tx of an injury arising out of employment
-Any side effect from preventative healthcare provided by employer
-Must cause disability or needs medical tx
-Must lose work time/impact ability to work
Physicians claims process
Give this one a try later!
-Primary tx phys: manages med. care and tx; IW can only have 1 PTP at a
time, and PTP can refer to consulting phys at employer expense
-Employer can have IW examined by phys of their choice
-Secondary tx phys: not primarily responsible for med tx, can examine and
treat IW
-PTP, secondary phys, QME/AME, consulting phys
, Delayed recovery
Give this one a try later!
-DR: does not improve in timely manner
P&S dates
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-If before 1/1/05: 1997 PDRS, rate on work restrictions
-If after 1/1/05: AMA Guides 5th ed., rate on impairment
Means of communication
Give this one a try later!
-All communication must be through letter/mail
Medical Unit
Give this one a try later!
-Executive med director; performs services related to delivery of med
benefits
-Est. policy and guidelines for tx and eval of IW
-Appoints QMEs; investigates complaints on QMEs
