QME Exam Study Materials

Author: Dana Livingstone-Lopez, Principal, TeachCE, Inc.

The intent of this article is to provide a common sense understanding of the issues associated with causation in California workers’ compensation. The article will review the following terms and the intent behind these terms in the medical legal context of CA Workers’ Compensation. Causation, AOE/COE, Aggravation, Exacerbation, Derivative effect, Compensable consequence, Specific injury, CT injury, Presumptive injury.

Author: Dana Livingstone-Lopez-Principal, TeachCe, Inc.

How can an AME or QME best fulfill the purpose of a medical-legal evaluation, and minimize the time required to bring a workers’ compensation claim to a proper resolution? This article contains a comprehensive outline, focusing on orthopedic injuries, but helpful with all specialties, ensuring that a physician fulfills the required elements of a medical-legal report. With a complete, thorough and excellent report, the parties will know what you concluded represents your best assessment of the issues, based on reasonable medical probability given the evidence that was available to you.

Author: Raymond F. Correio, Esq.

In 2001, the WCAB issued an en banc decision in Rolda v. Pitney Bowes, Inc. (2001) 66 Cal. Comp. Cases 241. Unlike a WCAB panel decision, an en banc decision by the WCAB is binding on all Workers’ Compensation Judges in the state. Labor Code §3208.3 provides that for a psychiatric injury to be compensable, certain conditions must be satisfied. Pursuant to Labor Code section 3208.3(b)(1), for a psych injury to be considered work related, an injured worker must establish by a preponderance of the evidence that actual events of employment predominantly caused the psychological injury.

Author: David Kizer, Esq.

Cumulative injury is one of the more difficult concepts for physicians in the workers’ compensation field. Physicians often must address the long-term effects of work exposure to the psyche, the back, extremities and/or internal organs and must do so while simultaneously explaining (to the satisfaction of a workers’ compensation judge) why some elements of the exposure contributed more to the overall snapshot of a worker’s disability while others did not. This article covers issues regarding dates of injury, multiple injuries and multiple employers.

Author: Duane H. Chernow, Esq.

From another perspective, this article details the cumulative trauma and the hazard of complexities for all participants in the workers’ compensation community. Physicians are routinely asked to comment whether a worker has sustained cumulative trauma, when the period of cumulative trauma occurred, whether there are multiple periods of cumulative trauma, or to discuss a “post-termination” cumulative trauma claim. Whether or not a worker has sustained a cumulative trauma is primarily a medical question. A physician is tasked with assessing whether the job activities and work exposure, performed over a period-of-time, is “injurious,” leading to a diagnosable medical condition requiring treatment, and potentially, impairment.

Author: Christopher Brigham, M.D.

The AMA Guides are the most widely used basis for defining permanent impairment. The Guides only assess impairment. Impairment is defined as the loss, loss of use, or derangement of any body part, organ system or organ function. In this article, the concepts of impairment evaluation and the appropriate application of the Guides are reviewed. This article specifically addresses Chapters 1 and 2 of the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition.

Author: Sherry German, CIR

This article addresses the use of the Almaraz-Guzman cases, as well as when an “analogy” can be used in the absence of that case law. When a worker is injured in California and they are determined to have reached maximum medical improvement with treatment, it is at this point the issue of permanent impairment is to be addressed in a permanent and stationary report by the primary treating physician, or a Qualified Medical Evaluator. If there is residual impairment, an impairment rating is required. The physician is directed to provide a rating based on the direct application of the instructions in the Guides. There are times, however, when an evaluator may opine that the impairment rating is either an inaccurate reflection of the impact a particular condition has on an injured worker’s ability to perform activities of daily living, or that a particular condition is simply not addressed in the Guides. This article addresses how to appropriately address this situation

Author: Raymond F. Correio, Esq.

Reporting physicians in the California Workers’ Compensation system whether treating physicians, Qualified Medical Examiners, or Agreed Medical Examiners are tasked with preparing not just medical reports but “medical-legal reports.”  To be relied upon by the parties and admissible as evidence at the Workers’ Compensation Appeals Board, medical-legal reports must constitute substantial evidence. In terms of assessing and evaluating a physician’s opinion on apportionment under Labor Code sections 4663 and 4664, it is critical to determine whether a physician’s opinion on apportionment in a medical-legal report or while being deposed, is based upon the correct legal standards as articulated by the WCAB and the Courts.  This article covers key points for physicians to consider when determining whether a medical-legal opinion on apportionment will constitute substantial evidence.

Author: David Kizer, Esq.

Under the Reform Act passed in 2004, (SB 899) medical control under section 4600 was by and large returned to employers via the newly established Medical Provider Networks (MPNs) (Labor Code section 4613 – 4616.7) provided the insurance carriers elected to have their own MPN. The MPNs, as with any other change in the system, were criticized by some for unavailability of physicians, delays in treatment, and lack of sufficient specialists. Others pointed to the accessibility of medical care, successful return to work ratios and costs savings to the system. In a 2013 Reform Bill (SB 863) the legislature further refined the MPN networks. This article highlights the current MPN system.

Author: Wm. J. Ordas, Esq.

“Substantial evidence” is a completely unique legal concept. When the term “substantial evidence” is used, the medical report has already met some minimum requirements of a medical-legal report. Now the question becomes whether the report is medical evidence that the court can rely upon to support a decision. This article discusses the concepts of substantial evidence, and how to apply them.

Author: David Dugan, Esq.

This article not only discusses the basic concepts of certain worker classes with certain diagnoses and the rebuttably presumptive causation issues, but also delves into the history, and politics of the statutes. In addition, new COVID-19 presumptions will be discussed.

Author: Steven Feinberg, M.D.

This article is for the benefit of a new QME, and a solid review for all QMEs. Dr. Feinberg, a well-renowned medical legal expert in the California worker’s compensation system, summarizes key concepts and defines commonly used terms in the medical legal field of workers’ compensation. Links are included for more in-depth information and to complete the CE testing.

This QME continuing education course introduces the participant to the CA work comp benefit system, PTP reporting requirements, and the dispute resolution process for both litigated and non-litigated cases. We then go into the required elements of the med-legal report including: History Taking, ADL importance, Diagnoses, Causation, Disability Status (MMI), Impairment, Apportionment with an emphasis on Escobedo, Functional Capacity/ Work Restrictions (SJDB) and Future Medical Care. Next, we go through a detailed rating analysis for a basic spine and shoulder injury. We finish with rules and regulations for filing and serving the ML report.