HCC QME EXAM: TERMS, DATES, AND
CONCEPTS
A QME certification is valid for how may years? - ANSWER-2 years (LC 139.2)
What are 3 requirements a physician must complete to become a certified QME? -
ANSWER-(1) QME competency exam
(2) 12-hour course in report writing
(3) Devote at least 1/3rd of total practice time to providing direct medical treatment (or
have served as a AME on 8+ occasions in past 12 months prior to application)
What are 2 reasons for termination/suspension of a QME without a hearing? -
ANSWER-(1) Licensing board suspends/revokes/terminates license to practice
(2) Failure to pay required fee (upon appointment and yearly thereafter)
What are the 6 reasons for discipline (suspension/termination) of QME that would
require a hearing? - ANSWER-(1) Violation of material statutory or administrative duty;
(2) Failure to follow medical procedures or qualifications;
(3) Failure to comply with the timeframe standards;
(4) Failure to meet licensing/certification requirements;
(5) Preparation of medical-legal evaluations that fail to meet the minimum standards for
those reports as established by the administrative director or the appeals board;
(6) Making material misrepresentations or false statements in an application for
appointment or reappointment as a qualified medical evaluator.
What is the definition of an Injury in WC claims? - ANSWER-(1) Injury or disease arising
out of employment
(2) Injury caused by treatment of an injury
(3) Reaction to, or side effect from care
What is the definition of Specific Injury in WC claims? - ANSWER-Injury from of a single
incident or exposure
What is the definition of Cumulative Injury in WC claims? - ANSWER-Repetitive trauma
over a period of time
What are the 2 requirements for a condition to be considered an injury in WC cases? -
ANSWER-(1) Cause a disability
(2) Need for medical treatment
What is the definition of occupational disease? - ANSWER-Disease/Injury that is caused
by work
,What are the 7 types of excluded injuries in WC Cases? - ANSWER-(1) Use of alcohol
or illegal drugs
(2) Self inflicted injuries
(3) Suicide
(4) Altercations, in which the injured employee is the initial physical aggressor
(5) Committing of a felony
(6) Off-duty recreational activities
(7) Psychiatric injuries claimed after notice of termination
What is the definition of Aggravation Causation? - ANSWER-A medical condition may
be present already, but work exposure makes it worse
What is principle of "taking employees as you find them"? - ANSWER-The employer
cannot avoid liability for an occupational injury by claiming that the injury would not have
happened if the worker had been in a different physical
or emotional condition before the accident.
What are the 3 criteria for compensation of psychiatric injuries in WC claims? -
ANSWER-(1) Diagnosed mental disorder
(2) Causes disability or need for medical treatment
(3) Employee can demonstrate that events of employment were predominant cause of
the injury
What is the definition of proximate cause? - ANSWER-Connection between injury and
employment
*Employment does not need to be the only cause of injury, just a contributing cause
What are the 4 basic conditions to establish a workers' compensation claim? -
ANSWER-(1) Injury
(2) Employment relationship
(3) Injury caused by the employment (AOE)
(4) Occurred in the course of the employment (COE)
What 3 requirements constitutes an aggravation of a pre-existing, non-industrial
condition in WC cases? - ANSWER-(1) Causes a temporary or permanent increase in
disability
(2) Creates a new need for medical treatment
(3) Requires a change in the existing course of treatment
What 4 items are determined by the DOI? - ANSWER-(1) Compensation rate
(2) Employers who are liable for the claim.
(3) Statute of limitations for particular procedures
(4) Regulations that will apply to the worker's injury
, What are 3 factors are needed to establish a causation determination? - ANSWER-(1)
Presence of pathological conditions and disability
(2) Relevant work exposures
(3) Non-industrial exposures (other causes of disease)
What are the 5 major types of causation? - ANSWER-(1) Direct
(2) Contributing
(3) Acceleration
(4) Precipitation
(5) Aggravation
What is the definition of direct causation? - ANSWER-Work exposures are directly
responsible for the health outcomes
What is the definition of contributing causation? - ANSWER-Several work factors led to
the disease
What is the definition of Acceleration Causation? - ANSWER-- Disease/injury is
accelerated by of work.
- (The date of the onset of the disease is much sooner than it would have been in the
absence of the exposure)
What is the definition of precipitation causation? - ANSWER-- Work exposure causes
the the illness.
(For example, an underlying tendency or asymptomatic problem was present, but the
work exposure causes it to clinically manifest.)
What are the 5 requirements needed to constitute a psychiatric injury in WC claims? -
ANSWER-(1) Actual events of employment were the predominant cause > 50% among
all combined causes of the psychiatric injury (except if the injury is a derivative of an
underlying physical injury)
(2) If the injury resulted from a violent act (contributed >= 35% causation)
(3) worked for at least 6 months (not continuously), unless the injury was caused by a
sudden and extraordinary employment condition
(4) Injury was not substantially caused by "lawful, nondiscriminatory, good faith
personnel actions" - 35% to more.
(e.g., being passed over for promotion or being transferred to another department)
(5) Claim can not be filed after notification of termination or layoff
What are 5 criteria for compensation of psychiatric claims after notice of
termination/layoff? - ANSWER-(1) Injury was the result of sudden and extraordinary
events of employment
(2) Employer had notice of the injury before the notice of termination or layoff.
(3) Psychiatric Medical records existing before the notice of termination/layoff
(4) Sexual or racial harassment.
CONCEPTS
A QME certification is valid for how may years? - ANSWER-2 years (LC 139.2)
What are 3 requirements a physician must complete to become a certified QME? -
ANSWER-(1) QME competency exam
(2) 12-hour course in report writing
(3) Devote at least 1/3rd of total practice time to providing direct medical treatment (or
have served as a AME on 8+ occasions in past 12 months prior to application)
What are 2 reasons for termination/suspension of a QME without a hearing? -
ANSWER-(1) Licensing board suspends/revokes/terminates license to practice
(2) Failure to pay required fee (upon appointment and yearly thereafter)
What are the 6 reasons for discipline (suspension/termination) of QME that would
require a hearing? - ANSWER-(1) Violation of material statutory or administrative duty;
(2) Failure to follow medical procedures or qualifications;
(3) Failure to comply with the timeframe standards;
(4) Failure to meet licensing/certification requirements;
(5) Preparation of medical-legal evaluations that fail to meet the minimum standards for
those reports as established by the administrative director or the appeals board;
(6) Making material misrepresentations or false statements in an application for
appointment or reappointment as a qualified medical evaluator.
What is the definition of an Injury in WC claims? - ANSWER-(1) Injury or disease arising
out of employment
(2) Injury caused by treatment of an injury
(3) Reaction to, or side effect from care
What is the definition of Specific Injury in WC claims? - ANSWER-Injury from of a single
incident or exposure
What is the definition of Cumulative Injury in WC claims? - ANSWER-Repetitive trauma
over a period of time
What are the 2 requirements for a condition to be considered an injury in WC cases? -
ANSWER-(1) Cause a disability
(2) Need for medical treatment
What is the definition of occupational disease? - ANSWER-Disease/Injury that is caused
by work
,What are the 7 types of excluded injuries in WC Cases? - ANSWER-(1) Use of alcohol
or illegal drugs
(2) Self inflicted injuries
(3) Suicide
(4) Altercations, in which the injured employee is the initial physical aggressor
(5) Committing of a felony
(6) Off-duty recreational activities
(7) Psychiatric injuries claimed after notice of termination
What is the definition of Aggravation Causation? - ANSWER-A medical condition may
be present already, but work exposure makes it worse
What is principle of "taking employees as you find them"? - ANSWER-The employer
cannot avoid liability for an occupational injury by claiming that the injury would not have
happened if the worker had been in a different physical
or emotional condition before the accident.
What are the 3 criteria for compensation of psychiatric injuries in WC claims? -
ANSWER-(1) Diagnosed mental disorder
(2) Causes disability or need for medical treatment
(3) Employee can demonstrate that events of employment were predominant cause of
the injury
What is the definition of proximate cause? - ANSWER-Connection between injury and
employment
*Employment does not need to be the only cause of injury, just a contributing cause
What are the 4 basic conditions to establish a workers' compensation claim? -
ANSWER-(1) Injury
(2) Employment relationship
(3) Injury caused by the employment (AOE)
(4) Occurred in the course of the employment (COE)
What 3 requirements constitutes an aggravation of a pre-existing, non-industrial
condition in WC cases? - ANSWER-(1) Causes a temporary or permanent increase in
disability
(2) Creates a new need for medical treatment
(3) Requires a change in the existing course of treatment
What 4 items are determined by the DOI? - ANSWER-(1) Compensation rate
(2) Employers who are liable for the claim.
(3) Statute of limitations for particular procedures
(4) Regulations that will apply to the worker's injury
, What are 3 factors are needed to establish a causation determination? - ANSWER-(1)
Presence of pathological conditions and disability
(2) Relevant work exposures
(3) Non-industrial exposures (other causes of disease)
What are the 5 major types of causation? - ANSWER-(1) Direct
(2) Contributing
(3) Acceleration
(4) Precipitation
(5) Aggravation
What is the definition of direct causation? - ANSWER-Work exposures are directly
responsible for the health outcomes
What is the definition of contributing causation? - ANSWER-Several work factors led to
the disease
What is the definition of Acceleration Causation? - ANSWER-- Disease/injury is
accelerated by of work.
- (The date of the onset of the disease is much sooner than it would have been in the
absence of the exposure)
What is the definition of precipitation causation? - ANSWER-- Work exposure causes
the the illness.
(For example, an underlying tendency or asymptomatic problem was present, but the
work exposure causes it to clinically manifest.)
What are the 5 requirements needed to constitute a psychiatric injury in WC claims? -
ANSWER-(1) Actual events of employment were the predominant cause > 50% among
all combined causes of the psychiatric injury (except if the injury is a derivative of an
underlying physical injury)
(2) If the injury resulted from a violent act (contributed >= 35% causation)
(3) worked for at least 6 months (not continuously), unless the injury was caused by a
sudden and extraordinary employment condition
(4) Injury was not substantially caused by "lawful, nondiscriminatory, good faith
personnel actions" - 35% to more.
(e.g., being passed over for promotion or being transferred to another department)
(5) Claim can not be filed after notification of termination or layoff
What are 5 criteria for compensation of psychiatric claims after notice of
termination/layoff? - ANSWER-(1) Injury was the result of sudden and extraordinary
events of employment
(2) Employer had notice of the injury before the notice of termination or layoff.
(3) Psychiatric Medical records existing before the notice of termination/layoff
(4) Sexual or racial harassment.
