HCC QME Exam | Key Terms, Dates & Core Concepts
|With 100% Verified Solutions
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 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 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.
(5) There is evidence that the DOI is after the date of notice of termination, but
before the effective date of the termination.
Who determines IW Impairment ratings? - ANSWER -A QME/PTP/AME
Who has the responsibility of assigning the permanent disability rating? -
ANSWER -The Disability Evaluation Unit (not physicians)
What can cause a Permanent Disability dispute? - ANSWER -The termination of
Temporary Disability by treating physician
,What is the cause for termination of Temporary Disability benefits? - ANSWER -
The finding of P&S / MMI by the primary treating physician.
What is Apportionment? - ANSWER -Estimate of approximate percentage of
permanent disability caused by a work-related injury and approximate percentage
caused by non work-related injuries.
Apportionment only applies to Permanent Disability.
What regions of the body are evaluated by QME/AME for Impairment Ratings? -
ANSWER -(1) Hearing
(2) Vision
(3) Mental and behavioral disorders
(4) Spine
(5) Upper extremities, including shoulders
(6) Lower extremities, including hip joints
(7) Head
(8) Face
(9) CV system
(10) Respiratory system
(11) All other systems/regions
What 4 injuries would automatically give an IW a 100% PD rating? - ANSWER -
(1) Loss of both eyes or sight in both eyes
(2) Loss of both hands or use of both hands
(3) Injury resulting in practically total paralysis
(4) Injury to the brain, resulting in incurable mental incapacitiy or insanity
What is the definition of "Impairment" in WC claims? - ANSWER -Amputation
of, loss of use of, or derangement of any body part, organ system or organ
function.
Ex: losing a finger or ability to speak
What is the definition of "Disability" in WC claims? - ANSWER -Alteration of an
individual's capacity to meet personal, social, or occupational demands or statutory
or regulatory requirements because of an Impairment.
Ex: Inability to type (Disability) due to loss of hand (Impairment).
, What is the purpose of the Combined Values Chart? - ANSWER -Used to
combine multiple impairment ratings into a summary value or WPI, used so the
WPI cannot exceed 100%
Who is responsible for assigning QME panels? - ANSWER -The Executive
Medical Director
How many days does either party in represented cases have to object to a medical
determination by the treating physician? - ANSWER -20 days
How many days does either party in unrepresented cases have to object to a
medical determination by the treating physician? - ANSWER -30 days
How many days does an unrepresented injured worker have to submit a request
for a QME panel after receiving form from employer? - ANSWER -10 days
How many days does an unrepresented worker have to schedule an evaluation
from a QME if a QME panel has not been issued? - ANSWER -After 20 days, if
request for QME panel is not issued
How many days an injured worker have to select a physician from the QME panel,
make an appointment for the exam, and inform the claims administrator of the
selection and appointment? - ANSWER -10 days
How many days does each party in a represented case have to strike one name off
a QME panel? - ANSWER -10 days after the assignment of the panel
How many days does a QME have to schedule an appointment with the injured
worker? - ANSWER -Within 60 days of a request for an appointment (up to 90
days)
How many days does a QME have to submit the Appointment Notification Form?
- ANSWER -Within 5 business days of making the appointment
What 16 events may require the need for a replacement panel? - ANSWER -(1)
Failure to serve the QME Appointment Notification Form;
(2) Disclosure of COI by an evaluator after an appointment has been made;
(3) Necessity for subsequent examination by a QME in a different specialty (due to
limitations in scope of practice or clinical competency)
(4) QME doesn't practice in the requested specialty
|With 100% Verified Solutions
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 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 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.
(5) There is evidence that the DOI is after the date of notice of termination, but
before the effective date of the termination.
Who determines IW Impairment ratings? - ANSWER -A QME/PTP/AME
Who has the responsibility of assigning the permanent disability rating? -
ANSWER -The Disability Evaluation Unit (not physicians)
What can cause a Permanent Disability dispute? - ANSWER -The termination of
Temporary Disability by treating physician
,What is the cause for termination of Temporary Disability benefits? - ANSWER -
The finding of P&S / MMI by the primary treating physician.
What is Apportionment? - ANSWER -Estimate of approximate percentage of
permanent disability caused by a work-related injury and approximate percentage
caused by non work-related injuries.
Apportionment only applies to Permanent Disability.
What regions of the body are evaluated by QME/AME for Impairment Ratings? -
ANSWER -(1) Hearing
(2) Vision
(3) Mental and behavioral disorders
(4) Spine
(5) Upper extremities, including shoulders
(6) Lower extremities, including hip joints
(7) Head
(8) Face
(9) CV system
(10) Respiratory system
(11) All other systems/regions
What 4 injuries would automatically give an IW a 100% PD rating? - ANSWER -
(1) Loss of both eyes or sight in both eyes
(2) Loss of both hands or use of both hands
(3) Injury resulting in practically total paralysis
(4) Injury to the brain, resulting in incurable mental incapacitiy or insanity
What is the definition of "Impairment" in WC claims? - ANSWER -Amputation
of, loss of use of, or derangement of any body part, organ system or organ
function.
Ex: losing a finger or ability to speak
What is the definition of "Disability" in WC claims? - ANSWER -Alteration of an
individual's capacity to meet personal, social, or occupational demands or statutory
or regulatory requirements because of an Impairment.
Ex: Inability to type (Disability) due to loss of hand (Impairment).
, What is the purpose of the Combined Values Chart? - ANSWER -Used to
combine multiple impairment ratings into a summary value or WPI, used so the
WPI cannot exceed 100%
Who is responsible for assigning QME panels? - ANSWER -The Executive
Medical Director
How many days does either party in represented cases have to object to a medical
determination by the treating physician? - ANSWER -20 days
How many days does either party in unrepresented cases have to object to a
medical determination by the treating physician? - ANSWER -30 days
How many days does an unrepresented injured worker have to submit a request
for a QME panel after receiving form from employer? - ANSWER -10 days
How many days does an unrepresented worker have to schedule an evaluation
from a QME if a QME panel has not been issued? - ANSWER -After 20 days, if
request for QME panel is not issued
How many days an injured worker have to select a physician from the QME panel,
make an appointment for the exam, and inform the claims administrator of the
selection and appointment? - ANSWER -10 days
How many days does each party in a represented case have to strike one name off
a QME panel? - ANSWER -10 days after the assignment of the panel
How many days does a QME have to schedule an appointment with the injured
worker? - ANSWER -Within 60 days of a request for an appointment (up to 90
days)
How many days does a QME have to submit the Appointment Notification Form?
- ANSWER -Within 5 business days of making the appointment
What 16 events may require the need for a replacement panel? - ANSWER -(1)
Failure to serve the QME Appointment Notification Form;
(2) Disclosure of COI by an evaluator after an appointment has been made;
(3) Necessity for subsequent examination by a QME in a different specialty (due to
limitations in scope of practice or clinical competency)
(4) QME doesn't practice in the requested specialty
