QME Study Test Questions with
Complete Solutions41
QME - ANSWERS-Qualified Medical Examiner
permanent and stationary - ANSWERS-When a condition reaches a state of maximal medical
improvement.
Escobedo case - ANSWERS--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 - ANSWERS-1. Did psych injury involve
"actual events of employment"? (IW has burden of proof)
2. Is there >50% industrial causation (IW burden)
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 - ANSWERS--Set standard that medical tx (MT) is not apportionable
Benson case - ANSWERS--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 - ANSWERS--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 - ANSWERS-WCAB defined roles for:
-physician
-DEU rater
-parties
-Work comp judge
Blackledge case: physician requirements - ANSWERS-1. Compare medical findings
2. List WPI for each med condition
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 - ANSWERS-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 - ANSWERS--Provide minimum level of benefits promptly
-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 - ANSWERS--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 - ANSWERS--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 - ANSWERS--Employer pays benefits no matter who caused injury, as long
as it occurred 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
Exclusive Remedy - ANSWERS-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 - ANSWERS--WC has defined benefits employer must pay
-WC is a statutory benefit w no arbitrary limits on freq, duration, or extent of services
Benefits provided by WC system - ANSWERS--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 - ANSWERS-WC judges and staff; first level in determining claim
Disability eval Unit - ANSWERS-Disability evaluator/raters that determine PD ratings
Info and Assistance Unit - ANSWERS--Assists on rights, benefits, and obligations under CA WC
laws
-Officer helps resolve misunderstandings, disputes, and complaints from claims for
compensation
Rehab Unit - ANSWERS-Makes determinations of disputes in vocational rehab
Audit and Enforcement Unit - ANSWERS-Conducts audits on insurance co., self insured
employer, and 3rd party admin.; ensures benefits are paid accurately and timely
Uninsured employer fund/Collections unit - ANSWERS-Pays benefits to IW w/ illegally uninsured
employer & pursues recovery
Complete Solutions41
QME - ANSWERS-Qualified Medical Examiner
permanent and stationary - ANSWERS-When a condition reaches a state of maximal medical
improvement.
Escobedo case - ANSWERS--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 - ANSWERS-1. Did psych injury involve
"actual events of employment"? (IW has burden of proof)
2. Is there >50% industrial causation (IW burden)
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 - ANSWERS--Set standard that medical tx (MT) is not apportionable
Benson case - ANSWERS--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 - ANSWERS--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 - ANSWERS-WCAB defined roles for:
-physician
-DEU rater
-parties
-Work comp judge
Blackledge case: physician requirements - ANSWERS-1. Compare medical findings
2. List WPI for each med condition
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 - ANSWERS-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 - ANSWERS--Provide minimum level of benefits promptly
-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 - ANSWERS--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 - ANSWERS--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 - ANSWERS--Employer pays benefits no matter who caused injury, as long
as it occurred 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
Exclusive Remedy - ANSWERS-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 - ANSWERS--WC has defined benefits employer must pay
-WC is a statutory benefit w no arbitrary limits on freq, duration, or extent of services
Benefits provided by WC system - ANSWERS--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 - ANSWERS-WC judges and staff; first level in determining claim
Disability eval Unit - ANSWERS-Disability evaluator/raters that determine PD ratings
Info and Assistance Unit - ANSWERS--Assists on rights, benefits, and obligations under CA WC
laws
-Officer helps resolve misunderstandings, disputes, and complaints from claims for
compensation
Rehab Unit - ANSWERS-Makes determinations of disputes in vocational rehab
Audit and Enforcement Unit - ANSWERS-Conducts audits on insurance co., self insured
employer, and 3rd party admin.; ensures benefits are paid accurately and timely
Uninsured employer fund/Collections unit - ANSWERS-Pays benefits to IW w/ illegally uninsured
employer & pursues recovery
