QME Latest Update 2024/2025
"Takes employee as they find him" - ANSWER--Employer liable even if employees lead unhealthy
lifestyle
-Employer can't avoid liability by stating that the injury wouldn't have happened if employee had
been in difft phys/emotional condition before accident
% of causation for psych injuries - ANSWER--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
4 factors of disability pre-2005 - ANSWER--Objective
-Subjective
-work restrictions
-loss of pre-injury capacity
4 factors of rating disability - ANSWER--Concentration/memory
-ADLs
-Social fxning
-Adaptation to stressful circumstances
*Impairment rated as: no, mild, moderate, marked, and extreme impairment
Acceleration (cause) - ANSWER--Work exposure accelerated the disease process; disease onset
sooner than it would have been if no exposure
ACOEM guidelines - ANSWER--Evaluations and management of common health problems and fxnal
recovery in workers
-Specific focus is RTW in 90 days
Additional QME office costs - ANSWER--$100/year per office
ADLs - ANSWER--Self care
-Personal hygiene
-Communication
-Phys. activity
-Sensory fxn
-Nonspecialized hard activities (grasp, lift)
-Travel
-Sexual fxn
Aggravation (cause) - ANSWER--Med. condition already present but exposure makes it worse
,QME Latest Update 2024/2025
Aggravation of non-industrial pre-existing disease - ANSWER--New injury; current employer is liable
-AKA acceleration or precipitation of sxs/lighting-up
-Causes temp or permanent increase in disability and creates new need for tx or change in existing
course of tx
-If flare-up from previous injury but not caused by current job, then current employer not liable
Alternative rating under Almaraz/Guzman - ANSWER-1. Begin w strict rating found in the chapter
address the injured body part
2. Explain what specific facts require an alternative rating
3. Provide analysis as to why alternative rating is more accurate
4. Set forth how Dr arrived at alt rating
5. State position with reasonable medical probability
Alternative work assignment - ANSWER--Moving worker to another job
-New position must provide wages w/in 15% of what was originally earned and w/in reasonable
distance; must be able to do job.
AMA guides assess... - ANSWER--Degree to which an impairment decreases ability to perform
common ADLs
American College of Occupational and Environmental Medicine (ACOEM) - ANSWER--Purpose is to
improve efficiency and accuracy w/ which the diagnostic process is conducted
-Improve effectiveness of individual tx and tx plans in relieving sxs and achieving fxnal improvement
and RTW
-Improve or restore health of workers w/ occupationally related diseases/illnesses or injuries
-Improve the quality of occupational medical care and disability management
AOE - ANSWER--Arising out of employment/caused by employment; relationship b/w exposure and
injury
-Physicians answer this question
-May be description of incident resulting in dmg to pt.
-May be work factors and activities and the resulting injury
Apportionment - ANSWER--Diff't sources of the permanent impairment; based on causation, and
applies to PD only
-Estimate of what % of PD is caused by work and what % is caused by other factors
-What part of disability (if any) would've existed due to a pre-existing condition or underlying disease
(how much disability would exist w/o effects of current injury).
-Disability directly resulting from an injury is not apportioned
-Asymptomatic disease before injury is apportioned if it would be a disability w/o the injury
, QME Latest Update 2024/2025
-Prior award is subtracted
Apportionment & pre-existing condition - ANSWER--Issue when an injury aggravates a pre-existing
condition
-Apportionment only when IW's condition doesn't return to level present pre-aggravation (inability
to work), then declared MMI and worse disability than before if new injury caused addtl disability
-No apportionment if pre-existing cond. didn't affect the IW's ability to work
Apportionment and liability in cumulative trauma - ANSWER--If exposed to harmful agents a diff't
jobs
-Liability goes to last employer
-If no compensation coverage, liability passes to most recent year of exposure
-Employer can try to split liability among as many other
Apportionment to a subsequent injury - ANSWER-1. Subsequent injury is unrelated to work injury
2. Subsequent injury is non-compensable
3. The subsequent injury caused a portion of IW's PD.
Assured & Fixed Benefits - ANSWER--WC has defined benefits employer must pay
-WC is a statutory benefit w no arbitrary limits on freq, duration, or extent of services
Attornys claims process - ANSWER--Applicant's attorney is IW's lawyer
-Compensated by fees deducted from PD award, unless WCAB awards nothing, then attorney gets
nothing
-Fees limited: determined by % of award
-Can't take IW $ unless gets order from WCAB
Audit and Enforcement Unit - ANSWER-Conducts audits on insurance co., self insured employer, and
3rd party admin.; ensures benefits are paid accurately and timely
Benefits provided by WC system - ANSWER--Medical
-TD payments: paid while injury is being tx, before it is PD
-PD payments: determined by loss of ADLs that contribute to WPI; compensates employee who does
not fully recover
-Vocational: no longer; now provides Supp Job Displacement Benefits (SJDB)
-Death: 1 dep: $125,000, 2 dep: 135,000, 3+ dep: 160,000
Benson case - ANSWER--Clarified parsing out impairment to different injury dates
-If they can't be parceled out, you can say they are "inextricably intertwined."
Benson v. WCAB (apportionment) - ANSWER--If more than one DOI, PD must be apportioned
amongst DOIs
"Takes employee as they find him" - ANSWER--Employer liable even if employees lead unhealthy
lifestyle
-Employer can't avoid liability by stating that the injury wouldn't have happened if employee had
been in difft phys/emotional condition before accident
% of causation for psych injuries - ANSWER--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
4 factors of disability pre-2005 - ANSWER--Objective
-Subjective
-work restrictions
-loss of pre-injury capacity
4 factors of rating disability - ANSWER--Concentration/memory
-ADLs
-Social fxning
-Adaptation to stressful circumstances
*Impairment rated as: no, mild, moderate, marked, and extreme impairment
Acceleration (cause) - ANSWER--Work exposure accelerated the disease process; disease onset
sooner than it would have been if no exposure
ACOEM guidelines - ANSWER--Evaluations and management of common health problems and fxnal
recovery in workers
-Specific focus is RTW in 90 days
Additional QME office costs - ANSWER--$100/year per office
ADLs - ANSWER--Self care
-Personal hygiene
-Communication
-Phys. activity
-Sensory fxn
-Nonspecialized hard activities (grasp, lift)
-Travel
-Sexual fxn
Aggravation (cause) - ANSWER--Med. condition already present but exposure makes it worse
,QME Latest Update 2024/2025
Aggravation of non-industrial pre-existing disease - ANSWER--New injury; current employer is liable
-AKA acceleration or precipitation of sxs/lighting-up
-Causes temp or permanent increase in disability and creates new need for tx or change in existing
course of tx
-If flare-up from previous injury but not caused by current job, then current employer not liable
Alternative rating under Almaraz/Guzman - ANSWER-1. Begin w strict rating found in the chapter
address the injured body part
2. Explain what specific facts require an alternative rating
3. Provide analysis as to why alternative rating is more accurate
4. Set forth how Dr arrived at alt rating
5. State position with reasonable medical probability
Alternative work assignment - ANSWER--Moving worker to another job
-New position must provide wages w/in 15% of what was originally earned and w/in reasonable
distance; must be able to do job.
AMA guides assess... - ANSWER--Degree to which an impairment decreases ability to perform
common ADLs
American College of Occupational and Environmental Medicine (ACOEM) - ANSWER--Purpose is to
improve efficiency and accuracy w/ which the diagnostic process is conducted
-Improve effectiveness of individual tx and tx plans in relieving sxs and achieving fxnal improvement
and RTW
-Improve or restore health of workers w/ occupationally related diseases/illnesses or injuries
-Improve the quality of occupational medical care and disability management
AOE - ANSWER--Arising out of employment/caused by employment; relationship b/w exposure and
injury
-Physicians answer this question
-May be description of incident resulting in dmg to pt.
-May be work factors and activities and the resulting injury
Apportionment - ANSWER--Diff't sources of the permanent impairment; based on causation, and
applies to PD only
-Estimate of what % of PD is caused by work and what % is caused by other factors
-What part of disability (if any) would've existed due to a pre-existing condition or underlying disease
(how much disability would exist w/o effects of current injury).
-Disability directly resulting from an injury is not apportioned
-Asymptomatic disease before injury is apportioned if it would be a disability w/o the injury
, QME Latest Update 2024/2025
-Prior award is subtracted
Apportionment & pre-existing condition - ANSWER--Issue when an injury aggravates a pre-existing
condition
-Apportionment only when IW's condition doesn't return to level present pre-aggravation (inability
to work), then declared MMI and worse disability than before if new injury caused addtl disability
-No apportionment if pre-existing cond. didn't affect the IW's ability to work
Apportionment and liability in cumulative trauma - ANSWER--If exposed to harmful agents a diff't
jobs
-Liability goes to last employer
-If no compensation coverage, liability passes to most recent year of exposure
-Employer can try to split liability among as many other
Apportionment to a subsequent injury - ANSWER-1. Subsequent injury is unrelated to work injury
2. Subsequent injury is non-compensable
3. The subsequent injury caused a portion of IW's PD.
Assured & Fixed Benefits - ANSWER--WC has defined benefits employer must pay
-WC is a statutory benefit w no arbitrary limits on freq, duration, or extent of services
Attornys claims process - ANSWER--Applicant's attorney is IW's lawyer
-Compensated by fees deducted from PD award, unless WCAB awards nothing, then attorney gets
nothing
-Fees limited: determined by % of award
-Can't take IW $ unless gets order from WCAB
Audit and Enforcement Unit - ANSWER-Conducts audits on insurance co., self insured employer, and
3rd party admin.; ensures benefits are paid accurately and timely
Benefits provided by WC system - ANSWER--Medical
-TD payments: paid while injury is being tx, before it is PD
-PD payments: determined by loss of ADLs that contribute to WPI; compensates employee who does
not fully recover
-Vocational: no longer; now provides Supp Job Displacement Benefits (SJDB)
-Death: 1 dep: $125,000, 2 dep: 135,000, 3+ dep: 160,000
Benson case - ANSWER--Clarified parsing out impairment to different injury dates
-If they can't be parceled out, you can say they are "inextricably intertwined."
Benson v. WCAB (apportionment) - ANSWER--If more than one DOI, PD must be apportioned
amongst DOIs
