QME Test 2026/ 2027
1. QME Qualified Medical Examiner
2. permanent and When a condition reaches a state of maximal medical improvement.
stationary
3. Escobedo case -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
4. Rolda 1. Did psych injury involve "actual events of employment"? (IW has burden of
issues/Limits on proof)
compensability 2. Is there >50% industrial causation (IW burden)
of psych issues 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)
5. Granado case -Set standard that medical tx (MT) is not apportionable
6. Benson case -Clarified parsing out impairment to ditterent injury dates
-If they can't be parceled out, you can say they are "inextricably intertwined."
7. Guzman -Alternative rating of disability (when case is complex/extraordinary and AMA
case/Al- good doesn't accurately reflect the persons impairment)
maraz-Guzman -WPI rating can be made if it's accurate and based on AMA guides (fairness is not
standard allowed anymore)
8. Blackledge v WCAB defined roles for:
BofA -physician
-DEU rater
-parties
-Work comp judge
, QME Test 2026/ 2027
9. Blackledge case: 1. Compare medical findings
physician re- 2. List WPI for each med condition
quirements 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
10. Alternative rat- 1. Begin w strict rating found in the chapter address the injured body part
ing under Al- 2. Explain what specific facts require an alternative rating
maraz/Guzman 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
11. Original intent of -Provide minimum level of benefits promptly
WC -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
12. Boyton act -1913: required most employers to have WC coverage
-Later expanded to include provision that when rating disability, persons dimin-
ished ability to compete in open job market should be considered
13. Historic compro- -Trade-ott of rights and benefits
mise -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
, QME
2. Exclusive remedy
3. Assured and fixed benefits
14. No Fault & excep- -Employer pays benefits no matter who caused injury, as long as it occurred
tions during employment
*Exceptions
-self inflicted injury
-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
15. Exclusive Reme- Workers' compensation benefits are the only benefits injured workers may receive
dy to compensate for a work-related injury. (Even if employer negligent)
-unless employer uninsured
-or third party is involved, that party can be sued
16. Assured & Fixed -WC has defined benefits employer must pay
Benefits -WC is a statutory benefit w no arbitrary limits on freq, duration, or extent of
services
17. Benefits provid- -Medical
ed by WC system -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
18. Claims adjudica- WC judges and statt; first level in determining claim
tion Unit
19. Disability eval Disability evaluator/raters that determine PD ratings
Unit
, QME
20. Info and Assis- -Assists on rights, benefits, and obligations under CA WC laws
tance Unit -Oflcer helps resolve misunderstandings, disputes, and complaints from claims
for compensation
21. Rehab Unit Makes determinations of disputes in vocational rehab
22. Audit and En- Conducts audits on insurance co., self insured employer, and 3rd party admin.;
forcement Unit ensures benefits are paid accurately and timely
23. Uninsured em- Pays benefits to IW w/ illegally uninsured employer & pursues recovery
ployer fund/Col-
lections unit
24. Medical Unit -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
25. DEU ratings 1. Formal: done at request of WC judge
2. Consultative: done on litigated cases at request of attorney or DW info assist
oflcer
3. Summary: non-litigated cases at request of claims admin or IW
26. Workers Comp -Uses electronic record keeping data to collect info from claims admin to help DIR
Info System oversee WC system
(WCIS) -All elements/documents of claim (reports, notices, med billing) are required to
be electronic as of 9/22/06
27. Subsequent in- -Source of add. compensation for IW who already had disability at time of injury
jury benefits -Need combined ettect of at least 70%
trust fund (SIBTF) -Employer can hire disabled workers w/o fear of liability for ettects of prev.
disability
1. QME Qualified Medical Examiner
2. permanent and When a condition reaches a state of maximal medical improvement.
stationary
3. Escobedo case -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
4. Rolda 1. Did psych injury involve "actual events of employment"? (IW has burden of
issues/Limits on proof)
compensability 2. Is there >50% industrial causation (IW burden)
of psych issues 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)
5. Granado case -Set standard that medical tx (MT) is not apportionable
6. Benson case -Clarified parsing out impairment to ditterent injury dates
-If they can't be parceled out, you can say they are "inextricably intertwined."
7. Guzman -Alternative rating of disability (when case is complex/extraordinary and AMA
case/Al- good doesn't accurately reflect the persons impairment)
maraz-Guzman -WPI rating can be made if it's accurate and based on AMA guides (fairness is not
standard allowed anymore)
8. Blackledge v WCAB defined roles for:
BofA -physician
-DEU rater
-parties
-Work comp judge
, QME Test 2026/ 2027
9. Blackledge case: 1. Compare medical findings
physician re- 2. List WPI for each med condition
quirements 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
10. Alternative rat- 1. Begin w strict rating found in the chapter address the injured body part
ing under Al- 2. Explain what specific facts require an alternative rating
maraz/Guzman 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
11. Original intent of -Provide minimum level of benefits promptly
WC -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
12. Boyton act -1913: required most employers to have WC coverage
-Later expanded to include provision that when rating disability, persons dimin-
ished ability to compete in open job market should be considered
13. Historic compro- -Trade-ott of rights and benefits
mise -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
, QME
2. Exclusive remedy
3. Assured and fixed benefits
14. No Fault & excep- -Employer pays benefits no matter who caused injury, as long as it occurred
tions during employment
*Exceptions
-self inflicted injury
-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
15. Exclusive Reme- Workers' compensation benefits are the only benefits injured workers may receive
dy to compensate for a work-related injury. (Even if employer negligent)
-unless employer uninsured
-or third party is involved, that party can be sued
16. Assured & Fixed -WC has defined benefits employer must pay
Benefits -WC is a statutory benefit w no arbitrary limits on freq, duration, or extent of
services
17. Benefits provid- -Medical
ed by WC system -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
18. Claims adjudica- WC judges and statt; first level in determining claim
tion Unit
19. Disability eval Disability evaluator/raters that determine PD ratings
Unit
, QME
20. Info and Assis- -Assists on rights, benefits, and obligations under CA WC laws
tance Unit -Oflcer helps resolve misunderstandings, disputes, and complaints from claims
for compensation
21. Rehab Unit Makes determinations of disputes in vocational rehab
22. Audit and En- Conducts audits on insurance co., self insured employer, and 3rd party admin.;
forcement Unit ensures benefits are paid accurately and timely
23. Uninsured em- Pays benefits to IW w/ illegally uninsured employer & pursues recovery
ployer fund/Col-
lections unit
24. Medical Unit -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
25. DEU ratings 1. Formal: done at request of WC judge
2. Consultative: done on litigated cases at request of attorney or DW info assist
oflcer
3. Summary: non-litigated cases at request of claims admin or IW
26. Workers Comp -Uses electronic record keeping data to collect info from claims admin to help DIR
Info System oversee WC system
(WCIS) -All elements/documents of claim (reports, notices, med billing) are required to
be electronic as of 9/22/06
27. Subsequent in- -Source of add. compensation for IW who already had disability at time of injury
jury benefits -Need combined ettect of at least 70%
trust fund (SIBTF) -Employer can hire disabled workers w/o fear of liability for ettects of prev.
disability
