QME EXAM NEWEST ACTUAL EXAM COMPLETE WITH 221 QUESTIONS AND CORRECT
ANSWERS |ALREADY GRADED A+
QME - (ANSWER)Qualified Medical Examiner
permanent and stationary - (ANSWER)When a condition reaches a state of maximal
medical improvement.
_&
@
Escobedo case - (ANSWER)-Set standard of reasonable medical probability (standard*+
a #
physician is expected to follow, that based on superior evidence, something is _%
$
probably/more likely than not) ^&
%
-These words turn the report into substantial evidence *()
^
&
Rolda issues/Limits on compensability of psych issues - (ANSWER)1. Did psych injury *
involve "actual events of employment"? (IW has burden of proof) (
2. Is there >50% industrial causation (IW burden) o
3. Was there personnel action and was it lawful, non-discriminatory, and in good faith? (
(Defense burden) *
4. Were personnel actions the substantial (>35-40%) cause of the psych injury. (defense &
burden) ^
%
Granado case - (ANSWER)-Set standard that medical tx (MT) is not apportionable $
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."
Guzman case/Almaraz-Guzman standard - (ANSWER)-Alternative rating of disability (when
case is complex/extraordinary and AMA good doesn't accurately reflect the persons
impairment)
-WPI rating can be made if it's accurate and based on AMA guides (fairness is not allowed
anymore)
Blackledge v BofA - (ANSWER)WCAB defined roles for:
-physician
-DEU rater
-parties
-Work comp judge
Blackledge case: physician requirements - (ANSWER)1. Compare medical findings
2. List WPI for each med condition
,QME EXAM NEWEST ACTUAL EXAM COMPLETE WITH 221 QUESTIONS AND CORRECT
ANSWERS |ALREADY GRADED A+
3. Select impairment in the range based on impact on ADLs
4. ADL analogies
-Role of evaluator is to assess WPI % by a report that sets forth facts and reasoning to
support conclusions and are in line with AMA & case law
_&
@
*+
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 *
(
Original intent of WC - (ANSWER)-Provide minimum level of benefits promptly o
-To prevent IW from becoming a burden on others and help IW return to work thru rehab (
-Help dependents if IW dies *
-MT for job related injuries/illness &
-TD benefits for lost wages ^
-PD benefits for finished ability to compete in open labor market %
$
Boyton act - (ANSWER)-1913: required most employers to have WC coverage
-Later expanded to include provision that when rating disability, persons diminished ability
to compete in open job market should be considered
Historic compromise - (ANSWER)-Trade-off of rights and benefits
-Employee gives up right to sue for lots of $ and gets protection from legal system against
discrimination
-Employer provides benefits regardless of fault in exchange for protection from lawsuits
-3 components
1. No fault
2. Exclusive remedy
3. Assured and fixed benefits
No Fault & exceptions - (ANSWER)-Employer pays benefits no matter who caused injury, as
long as it occurred during employment
*Exceptions
-self inflicted injury
,QME EXAM NEWEST ACTUAL EXAM COMPLETE WITH 221 QUESTIONS AND CORRECT
ANSWERS |ALREADY GRADED A+
-injury from serious/willful misconduct by employee: benefits reduced by half unless
employee died or has PD of 70% or more
-injury from failure of employer to comply with health and safety reg
-employee was under 16yo
_&
@
*+
Exclusive Remedy - (ANSWER)Workers' compensation benefits are the only benefits injured #
_%
workers may receive to compensate for a work-related injury. (Even if employer negligent) $
-unless employer uninsured ^&
%
-or third party is involved, that party can be sued *()
^
&
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 (
o
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 $
Claims adjudication Unit - (ANSWER)WC judges and staff; first level in determining claim
Disability eval Unit - (ANSWER)Disability evaluator/raters that determine PD ratings
Info and Assistance Unit - (ANSWER)-Assists on rights, benefits, and obligations under CA
WC laws
-Officer helps resolve misunderstandings, disputes, and complaints from claims for
compensation
Rehab Unit - (ANSWER)Makes determinations of disputes in vocational rehab
Audit and Enforcement Unit - (ANSWER)Conducts audits on insurance co., self insured
employer, and 3rd party admin.; ensures benefits are paid accurately and timely
Uninsured employer fund/Collections unit - (ANSWER)Pays benefits to IW w/ illegally
uninsured employer & pursues recovery
, QME EXAM NEWEST ACTUAL EXAM COMPLETE WITH 221 QUESTIONS AND CORRECT
ANSWERS |ALREADY GRADED A+
Medical Unit - (ANSWER)-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
-Approves/certifies and oversees MPNs and HCO _&
@
-Helps set med fee schedule *+
#
_%
$
DEU ratings - (ANSWER)1. Formal: done at request of WC judge ^&
%
2. Consultative: done on litigated cases at request of attorney or DW info assist officer*() ^
3. Summary: non-litigated cases at request of claims admin or IW &
*
Workers Comp Info System (WCIS) - (ANSWER)-Uses electronic record keeping data to (
collect info from claims admin to help DIR oversee WC system o
-All elements/documents of claim (reports, notices, med billing) are required to be (
electronic as of 9/22/06 *
&
Subsequent injury benefits trust fund (SIBTF) - (ANSWER)-Source of add. compensation for ^
IW who already had disability at time of injury %
-Need combined effect of at least 70% $
-Employer can hire disabled workers w/o fear of liability for effects of prev. disability
WCAB - (ANSWER)Workers Comp Appeals Board; 7 commissioners, 5 of which are
attorneys
-Independent judicial body w/in DIR
-Adopt rules of procedure
-Set policies
-Interpret regulations
-Rvw petitions for reconsideration of decisions made by WC judges
DIR - (ANSWER)Dept of Industrial Relations
DWC - (ANSWER)Division of Workers' Compensation djd
-State of CA > Dept of Consumer Affairs > DIR > DWC > Medical Unit > QME
Statute v. Regulation - (ANSWER)1. Defines eligibility, types and levels of benefits, system
operation; written by legislature and signed by governor
2. Specifics, day to day operation of WC system (time limits, contents of reports)
ANSWERS |ALREADY GRADED A+
QME - (ANSWER)Qualified Medical Examiner
permanent and stationary - (ANSWER)When a condition reaches a state of maximal
medical improvement.
_&
@
Escobedo case - (ANSWER)-Set standard of reasonable medical probability (standard*+
a #
physician is expected to follow, that based on superior evidence, something is _%
$
probably/more likely than not) ^&
%
-These words turn the report into substantial evidence *()
^
&
Rolda issues/Limits on compensability of psych issues - (ANSWER)1. Did psych injury *
involve "actual events of employment"? (IW has burden of proof) (
2. Is there >50% industrial causation (IW burden) o
3. Was there personnel action and was it lawful, non-discriminatory, and in good faith? (
(Defense burden) *
4. Were personnel actions the substantial (>35-40%) cause of the psych injury. (defense &
burden) ^
%
Granado case - (ANSWER)-Set standard that medical tx (MT) is not apportionable $
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."
Guzman case/Almaraz-Guzman standard - (ANSWER)-Alternative rating of disability (when
case is complex/extraordinary and AMA good doesn't accurately reflect the persons
impairment)
-WPI rating can be made if it's accurate and based on AMA guides (fairness is not allowed
anymore)
Blackledge v BofA - (ANSWER)WCAB defined roles for:
-physician
-DEU rater
-parties
-Work comp judge
Blackledge case: physician requirements - (ANSWER)1. Compare medical findings
2. List WPI for each med condition
,QME EXAM NEWEST ACTUAL EXAM COMPLETE WITH 221 QUESTIONS AND CORRECT
ANSWERS |ALREADY GRADED A+
3. Select impairment in the range based on impact on ADLs
4. ADL analogies
-Role of evaluator is to assess WPI % by a report that sets forth facts and reasoning to
support conclusions and are in line with AMA & case law
_&
@
*+
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 *
(
Original intent of WC - (ANSWER)-Provide minimum level of benefits promptly o
-To prevent IW from becoming a burden on others and help IW return to work thru rehab (
-Help dependents if IW dies *
-MT for job related injuries/illness &
-TD benefits for lost wages ^
-PD benefits for finished ability to compete in open labor market %
$
Boyton act - (ANSWER)-1913: required most employers to have WC coverage
-Later expanded to include provision that when rating disability, persons diminished ability
to compete in open job market should be considered
Historic compromise - (ANSWER)-Trade-off of rights and benefits
-Employee gives up right to sue for lots of $ and gets protection from legal system against
discrimination
-Employer provides benefits regardless of fault in exchange for protection from lawsuits
-3 components
1. No fault
2. Exclusive remedy
3. Assured and fixed benefits
No Fault & exceptions - (ANSWER)-Employer pays benefits no matter who caused injury, as
long as it occurred during employment
*Exceptions
-self inflicted injury
,QME EXAM NEWEST ACTUAL EXAM COMPLETE WITH 221 QUESTIONS AND CORRECT
ANSWERS |ALREADY GRADED A+
-injury from serious/willful misconduct by employee: benefits reduced by half unless
employee died or has PD of 70% or more
-injury from failure of employer to comply with health and safety reg
-employee was under 16yo
_&
@
*+
Exclusive Remedy - (ANSWER)Workers' compensation benefits are the only benefits injured #
_%
workers may receive to compensate for a work-related injury. (Even if employer negligent) $
-unless employer uninsured ^&
%
-or third party is involved, that party can be sued *()
^
&
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 (
o
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 $
Claims adjudication Unit - (ANSWER)WC judges and staff; first level in determining claim
Disability eval Unit - (ANSWER)Disability evaluator/raters that determine PD ratings
Info and Assistance Unit - (ANSWER)-Assists on rights, benefits, and obligations under CA
WC laws
-Officer helps resolve misunderstandings, disputes, and complaints from claims for
compensation
Rehab Unit - (ANSWER)Makes determinations of disputes in vocational rehab
Audit and Enforcement Unit - (ANSWER)Conducts audits on insurance co., self insured
employer, and 3rd party admin.; ensures benefits are paid accurately and timely
Uninsured employer fund/Collections unit - (ANSWER)Pays benefits to IW w/ illegally
uninsured employer & pursues recovery
, QME EXAM NEWEST ACTUAL EXAM COMPLETE WITH 221 QUESTIONS AND CORRECT
ANSWERS |ALREADY GRADED A+
Medical Unit - (ANSWER)-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
-Approves/certifies and oversees MPNs and HCO _&
@
-Helps set med fee schedule *+
#
_%
$
DEU ratings - (ANSWER)1. Formal: done at request of WC judge ^&
%
2. Consultative: done on litigated cases at request of attorney or DW info assist officer*() ^
3. Summary: non-litigated cases at request of claims admin or IW &
*
Workers Comp Info System (WCIS) - (ANSWER)-Uses electronic record keeping data to (
collect info from claims admin to help DIR oversee WC system o
-All elements/documents of claim (reports, notices, med billing) are required to be (
electronic as of 9/22/06 *
&
Subsequent injury benefits trust fund (SIBTF) - (ANSWER)-Source of add. compensation for ^
IW who already had disability at time of injury %
-Need combined effect of at least 70% $
-Employer can hire disabled workers w/o fear of liability for effects of prev. disability
WCAB - (ANSWER)Workers Comp Appeals Board; 7 commissioners, 5 of which are
attorneys
-Independent judicial body w/in DIR
-Adopt rules of procedure
-Set policies
-Interpret regulations
-Rvw petitions for reconsideration of decisions made by WC judges
DIR - (ANSWER)Dept of Industrial Relations
DWC - (ANSWER)Division of Workers' Compensation djd
-State of CA > Dept of Consumer Affairs > DIR > DWC > Medical Unit > QME
Statute v. Regulation - (ANSWER)1. Defines eligibility, types and levels of benefits, system
operation; written by legislature and signed by governor
2. Specifics, day to day operation of WC system (time limits, contents of reports)
