HCC QME Exam: Terms, Dates, and Concepts || All Accurate.
A QME certification is valid for how may years? correct answers 2 years (LC 139.2)
What are 3 requirements a physician must complete to become a certified QME? correct
answers (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? correct answers
(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? correct answers (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? correct answers (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? correct answers Injury from of a
single incident or exposure
What is the definition of Cumulative Injury in WC claims? correct answers Repetitive trauma
over a period of time
What are the 2 requirements for a condition to be considered an injury in WC cases? correct
answers (1) Cause a disability
(2) Need for medical treatment
What is the definition of occupational disease? correct answers Disease/Injury that is caused
by work
What are the 7 types of excluded injuries in WC Cases? correct answers (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 are the 4 basic conditions to establish a workers' compensation claim? correct answers
(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? correct answers (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? correct answers (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? correct answers (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? correct answers (1) Direct
(2) Contributing
(3) Acceleration
(4) Precipitation
(5) Aggravation
What is the definition of direct causation? correct answers Work exposures are directly
responsible for the health outcomes
What is the definition of contributing causation? correct answers Several work factors led to
the disease
What is the definition of Acceleration Causation? correct answers - 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? correct answers - 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? correct answers A medical condition may
be present already, but work exposure makes it worse
What is principle of "taking employees as you find them"? correct answers 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? correct
answers (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? correct answers 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? correct
answers (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?
correct answers (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? correct answers A QME/PTP/AME
Who has the responsibility of assigning the permanent disability rating? correct answers The
Disability Evaluation Unit (not physicians)
What can cause a Permanent Disability dispute? correct answers The termination of
Temporary Disability by treating physician
What is the cause for termination of Temporary Disability benefits? correct answers The
finding of P&S / MMI by the primary treating physician.
What is Apportionment? correct answers 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.
A QME certification is valid for how may years? correct answers 2 years (LC 139.2)
What are 3 requirements a physician must complete to become a certified QME? correct
answers (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? correct answers
(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? correct answers (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? correct answers (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? correct answers Injury from of a
single incident or exposure
What is the definition of Cumulative Injury in WC claims? correct answers Repetitive trauma
over a period of time
What are the 2 requirements for a condition to be considered an injury in WC cases? correct
answers (1) Cause a disability
(2) Need for medical treatment
What is the definition of occupational disease? correct answers Disease/Injury that is caused
by work
What are the 7 types of excluded injuries in WC Cases? correct answers (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 are the 4 basic conditions to establish a workers' compensation claim? correct answers
(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? correct answers (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? correct answers (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? correct answers (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? correct answers (1) Direct
(2) Contributing
(3) Acceleration
(4) Precipitation
(5) Aggravation
What is the definition of direct causation? correct answers Work exposures are directly
responsible for the health outcomes
What is the definition of contributing causation? correct answers Several work factors led to
the disease
What is the definition of Acceleration Causation? correct answers - 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? correct answers - 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? correct answers A medical condition may
be present already, but work exposure makes it worse
What is principle of "taking employees as you find them"? correct answers 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? correct
answers (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? correct answers 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? correct
answers (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?
correct answers (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? correct answers A QME/PTP/AME
Who has the responsibility of assigning the permanent disability rating? correct answers The
Disability Evaluation Unit (not physicians)
What can cause a Permanent Disability dispute? correct answers The termination of
Temporary Disability by treating physician
What is the cause for termination of Temporary Disability benefits? correct answers The
finding of P&S / MMI by the primary treating physician.
What is Apportionment? correct answers 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.
