What is the DWC Medical Unit and what does it do?

The Medical Unit is a unit within the state Division of Workers’ Compensation (DWC) that manages medical issues in workers’ compensation. The DWC Medical Unit issues QME panels to injured workers and claims administrators, oversees medical provider networks (MPNs), health care organizations (HCOs), utilization review and medical treatment guidelines. The Medical Unit also appoints qualified medical evaluators (QMEs), spinal surgery second opinion physicians (SSSOPs) and independent medical reviewers (IMRs). These physicians help resolve medical disputes in the workers’ compensation system by issuing medical opinions that can be used as evidence before the Workers’ Compensation Appeals Board. The unit also investigates complaints against currently certified QMEs that allege billing violations and violations of guidelines contained in the Labor Code, the regulations, and other laws concerning a QME’s conduct of an evaluation and/or preparation or submission of a report.

You may reach the Medical Unit by calling 510-286-3700 or 1-800-794-6900.

What are the Labor Code sections and regulations that apply to QMEs?

Labor Code section 139.2 sets forth the law regarding appointment, qualification, termination, guidelines, procedures and admissibility of medical evaluations and submission of reports.  Labor Code sections 4628, 4060, 4062.1 and 4062.2 set forth evaluation and reporting requirements.  The QME regulations are found at California Code of Regulations, title 8, sections 1 through 159.  The medical-legal fee schedule is found at sections 9793 through 9795.

How many days do I have to complete the QME report?

The QME must prepare and submit an initial or follow-up comprehensive medical-legal evaluation within 30 days from the date the QME has seen the employee. (8 CCR § 38)You may not request an extension because the carrier failed to provide the injured worker’s medical records or previous medical tests. (Labor Code § 139.2(l)(A), 8 CCR § 38).

What is the time frame for supplemental reports?

You have 60 days from the date of the written request for a supplemental report.  The time frame may be extended up to 30 additional days if the parties agree without the need to request an extension from the medical director. (8 CCR § 38(h))

Who sets up the interpreter service at a QME evaluation?

Interpreter service must be from a state certified interpreter. The QME should note in the appointment notification form that a certified interpreter is required. When making the appointment, your staff should ask the injured worker which language is needed. The claims adjuster will make the necessary arrangements and also pay the interpreter. (Labor Code § 5811, 8 CCR § 9795.3, 8 CCR § 34(c))

What are the grounds for granting an extension on completing the med-legal report?

You must complete the QME form 112 (QME/AME Time Frame Extension Request) and send the original to the DWC Medical Unit with copies to the injured worker and the insurance carrier five days before the report is due to be served on the parties. The  valid reasons for an extension are : 1) you requested that the injured worker have medical tests and you are waiting for the results 2) you requested a consult and are waiting for the consultant’s report 3) good cause (medical emergency for you or your family, death in your family, natural disaster or other community catastrophes that interrupt the operation of the evaluator’s office): The computer breaking down or a staff member quitting are not considered good cause. Extensions for good cause may not exceed 15 days from the date the report is required to be served.

You may not request an extension because the carrier failed to provide the injured worker’s medical records or previous medical tests. (Labor Code § 139.2(l)(A), 8 CCR § 38)

How long of an extension will I be able to obtain for issuing the QME report?

If the extension is being requested due to good cause as defined above, you may receive a maximum extension of 15 days. If the extension is being requested because you are writing for test results or a consult report, then you may receive a maximum extension of 30 days.

With whom may I consult if more medical information is required?

You may only consult physicians who have treated the injured worker for this injury. ( 8 CCR § 35(i) and (j))ext.

What is the purpose of sending the medical and non-medical records to the QME?

These records give the QME a history of the injury. The treatment records document the problems that the injured worker is having from the injury. Test results such as MRIs are forwarded so that the QME will not have to duplicate the tests. Medical records on treatment prior to the injury are often sent to help determine how much of the permanent disability is due to this injury and how much may be due to a prior injury or accident. Non-medical records, such as a letter from the carrier, are sent to provide information regarding the injury to the QME doctor.

What are a QME’s responsibilities in preparing a QME Appointment Notification Form (Form 110)?

Whenever a QME makes an appointment for a comprehensive medical-legal evaluation, the QME must complete a QME Appointment Notification Form (Form 110). No Form 110 is acceptable if it contains formatting or any language that is in addition to or different from that stated in the version published on the DIR Web site and no exceptions to this policy will apply. To “complete” the form, the QME must ensure that all of the blanks are filled out with complete and accurate information received from the party requesting the appointment. Make an effort any lady luck within beste live blackjack casinos.

“Location of appointment” must include the complete address listed for the QME on the panel from which the QME has been selected. The appointment may not be scheduled for any other location unless the injured worker has first agreed in writing to be evaluated at a different location, at which the QME must be currently certified.

The selected QME’s name must be entered on two lines, with: (1) a signature entered when the QME is satisfied that the form has been filled out with complete and accurate information, and (2) the QME’s name printed or typed immediately below the signature.

If the QME determines that a consultation is necessary, and  the consulting physician is not selected by the parties from a QME panel issued by the Medical Unit, the referring QME must arrange the consultation appointment and advise the injured employee and the claims administrator, or if none the employer, using Form 110. For clarity, it is appropriate to indicate the consulting physician’s name on the same line as “location of appointment.”

The completed Form 110 must be postmarked or sent by facsimile to the employee and the claims administrator, or if none the employer, within five business days of the date the appointment was made. In a represented case, a copy of the completed form shall also be sent to the attorney who represents each party, if known.