Suzanne Honor-Vangerov

James Fisher

Division of Workers’ CompensationMedical Unit

QME Panel Process LC 4060, 4061, 4062 Spinal Surgery Second Opinion Process

QME ProcessLabor Code 4060 Pre April 19, 2004

Before Denial of ClaimAOE/COE ExaminationConsultant or QME selected by Employer

After Denial of ClaimQME ExaminationSelected by Injured Worker/Applicant’s AttorneyAny QME in the state

QME ProcessLC 4060

Post April 19, 2004Before Denial of Claim

RepresentedPanel QME. Panel chosen per 4062.2.4062.2 not effective for dates of

injury prior to January 1, 2005.

UnrepresentedPanel QME. Employer requests IW get a panel. Panel chosen per 4062.1.

After Denial of ClaimUnrepresentedPanel QME. Employer cannot request IW get a panel.Panel chosen per 4062.1.

RepresentedPanel QME. Panel chosen per 4062.2.4062.2 not effective for dates of

injury prior to January 1, 2005.

QME ProcessLC 4061

Permanent Disability DisputesUnrepresented

No time limit for dispute to be raised.

Panel chosen per 4062.1.

Represented No time limit for dispute to be

raised.

Employer and Applicant’s attorney attempt to agree on an AME within 10 - 20 days.

If no agreement, panel chosen per 4062.2.

Not effective for dates of injury prior to January 1, 2005.

QME ProcessLC 4062

All Other DisputesUnrepresented

Object within 30 days from receipt of PTP report.

Panel chosen per 4062.1.

Represented Object within 20 days from

receipt of PTP report.

Employer and Applicant’s attorney attempt to agree on an AME within 10 - 20 days.

If no agreement, panel chosen per 4062.2.

Not effective for dates of injury prior to January 1, 2005.

QME ProcessLC 4062.1

Unrepresented PanelsMust use our form. Can be on letterhead, but no other

changes to the form permitted. The form must be completely filled out. New forms are in the works.

The employer needs to provide the form to the injured worker with any notices required by 4060, 4061 or 4062.

Notice needs to spell out the statutory deadlines.The injured worker has 10 days to submit the form to

DWC Medical Unit.

LC 4062.1 Unrepresented Panels - cont.

If injured worker doesn’t submit the form, the employer can submit it.

The medical specialty is chosen by the requestor.The injured worker has 10 days from the panel issue

date to select a QME and make an appointment. If the injured worker doesn’t select a QME and make

an appointment within 10 days, the employer can make the selection.

QME ProcessLC 4062.2

Represented PanelsFor dates of injury on or after January 1, 2005.Parties must try to agree to an AME first.Either party can request QME panel if no AME is

chosen within 10 - 20 days.Party submitting the request for QME selects the

medical specialty.The parties have 10 days after the QME panel is

issued to choose an Agreed QME.

LC 4062.2Represented Panels - cont.

If the parties can’t agree on a QME from the panel, each one can strike one name from the list.

The remaining QME will do the evaluation. If either party fails to exercise their right to strike a name

within three working days, the other party can select a QME from doctors remaining on the panel.

The employee must make the appointment and notify the employer within 10 days of the QME selection. If the employee doesn’t make the appointment within 10 days, the employer can make it.

When is a Panel Issued?When a properly filled out request form is received.

– Must have DOI, Claim Number, Specialty and Requestor’s Signature.

– Claims adjusters must submit proof of notice to the injured worker.

We have 15 working days from date of receipt to issue the panel. ONLY ON UNREPRESENTED CLAIMS.– If we miss our deadline, requestor can choose QME of his

or her choice.

Number of PanelsNo panel will be issued if there is an existing open

panel in our system unless:– None of the panel doctors is available.

– If previous panel was already used for a different claim.

– If claim was settled or resolved at the WCAB.

– 4060 claims.

There is only one QME per case. (LC 4064)– If there is a need for more than one specialty, the QME can

get a consultation from an appropriate specialist. (Section 32)

– If a new issue arises after the injured worker has seen a QME, that QME remains on the case unless he or she becomes unavailable. A new panel will then be issued. (LC 4067)

Special Circumstances

Injured worker has sole right to get panel.– When the claim has already been denied.– When the claims adjuster hasn’t objected to

either the PD or the treatment recommendations of the PTP.

Replacement Panels

Section 31.5– QME doesn’t practice in specialty requested.

– QME can’t schedule an appointment within 60 days.

– Employee changed residence since panel was issued.

– Doctor on panel is in same group practice as another doctor on the panel.

– PTP is on the panel.

– New panel based on employee’s work address (both parties must agree.)

– Medical Director can replace for medical “good cause”.

– Medical Director can change specialty if appropriate.

Replacement Panels, cont.

QME is unavailable per section 33. – Notifies Medical Unit of unavailability by submitting form.

• Change of address

• Medical or Family emergency

– Can’t simply deny access to unrepresented injured workers.

Violation of section 34. – Must send appointment notification within 5 days.

– Must make appointment at office address on panel.

– Must notify if an interpreter needed.

Other Valid Replacement ReasonsDoctor on panel from same office as PTP. (Section 31)Late Reports. (Section 38)

– QME must issue report within 30 days of the exam (DOI after 1/1/94).

– QME must submit supplemental reports within 60 days of request.

– Extensions can be granted for good cause.

Ex Parte Communication. (LC 4062.5 Section 40, 41)QME Bias. (Section 41)

Invalid Reasons for Replacement

Doctors on panel are too far away.– We will change to work address with agreement of

both parties.

– If the selected specialty has too few doctors in the pool, we’ll change the specialty with the agreement of both parties.

Injured worker or adjuster doesn’t like anyone on the panel.

Injured worker changed his or her mind about the specialty.

Spinal Surgery Second Opinion

LC 4062 (b) PTP requests Spinal Surgery authorization

Employer must object within 10 days from receipt of PTP report.

Unrepresented Injured Workers

DWC will assign SSSO doctor at random.

Appointment, if needed, set on expedited basis.

Report served within 45 days from receipt of initial authorization request.

Spinal Surgery Second OpinionRepresented Injured Workers

Parties have 10 days to agree on a SSSO doctor.

If no agreement, DWC will assign at random.

Appointment, if needed, set on expedited basis.

Report served within 45 days from receipt of initial authorization request.

Spinal Surgery Second Opinion

SSSO Doctor recommends surgery– Employer must provide

surgery

SSSO Doctor doesn’t recommend surgery– Employer must file

DOR for a hearing

For More Information

For information on-line go to our web site– http://www.dir.ca.gov

• Click on Workers’ Compensation– Announcements

– DWC/WCAB Forum

– Forms and Guides

– Frequently Asked Questions

– DWC Newsline Archive