Panel QME referrals to other specialties (California)

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Panel QME referrals to other specialties (California)

Postby laesquire on Tue Oct 06, 2009 10:34 am

SCENARIO:

1. Applicant is represented on a denied case.

2. Applicant picks PTP who issues various reports then eventually MMI.

3. The Defense deposes Applicant's personal physician who says Applicant's condition is NOT work related.

4. About six months later Applicant Attorney suggests an AME under 4062.2 then demands a Panel QME. A panel QME report is issued. The Panel QME wants to send Applicant out to four other specialties.

QUESTION:
1. Does the Panel QME pick the other specilaties for consults?



Notes:

I have reviewed labor code 4062.2 (b) and it does not seem to specify a timeline to demand a Panel QME.
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Re: Panel QME referrals to other specialties (California)

Postby chirogeek on Tue Oct 13, 2009 5:45 am

This should help:

8CCR § 32. Consultations.

(a) In any case where an acupuncturist has been selected by the injured worker from a three-member panel and an issue of disability is in dispute, the acupuncturist shall request a consult from a QME defined under section 1(z) to evaluate the disability issue(s). The acupuncturist shall evaluate all other issues as required for a complete evaluation. If requested by the QME acupuncturist to obtain a QME to provide the consulting evaluation, the Medical Director shall issue a panel within fifteen (15) days of the request in the specialty selected by the QME acupuncturist.

(b) Except as provided in subdivision 32(a) above, no QME may obtain a consultation for the purpose of obtaining an opinion regarding permanent disability and apportionment consistent with the requirements of Labor Code sections 4660 through 4664 and the AMA Guides.

(c) For injuries occurring on or after January 1, 1994, a QME may obtain a consultation from any physician as reasonable and necessary pursuant to Labor Code section 4064(a).

(d) Whenever an Agreed Panel QME or a QME determines that a consultation is necessary pursuant to this section and the physician selected for the consultation is not selected by the parties from a QME panel issued by the Medical Director, the referring QME must arrange the consultation appointment and advise the injured employee and the claims administrator, or if none the employer, and each party's attorney if any, in writing of the appointment date, time and place by use of QME Form 110 (QME Appointment Notification Form)(See, 8 Cal. Code Regs. § 110).

(e) The consulting physician shall serve the consulting report on the referring QME. Upon receipt of the consulting physician's report, the referring evaluator shall review the consulting physician's report, incorporate that report by reference into the referring evaluator's medical-legal report and comment on the consulting physician's findings and conclusions in the discussion sections of the evaluator's report.

(f) The referring QME shall file the comprehensive medical-legal report within the time periods specified in section 38 of Title 8 of the California Code of Regulations. In the event a consulting physician's report has not been received, or will not be received, in time to comply with the time periods, the referring QME shall serve the comprehensive medical-legal report timely, and upon receipt of the consulting physician's report, the referring evaluator shall, within fifteen (15) calendar days of receipt of the consulting report, issue a supplemental report that incorporates the consulting physician's report by reference, and comments on whether and how the findings in the consulting report change the referring evaluator's opinions. The referring evaluator shall list, in the report commenting on a consulting physician's report, all reports and information received from each party for the consulting physician, indicate whether each item was forwarded to the consulting physician, and for items not forwarded the reason the referring evaluator determined it was not necessary to forward the item to the consulting physician.


(g) With the exception of verbal communications between an injured worker and the consulting physician in the course of the consulting examination, all other communications by the parties, as well as any reports and other information from the parties for the consulting physician, if any, shall be made in writing directed only to the referring QME, who may forward such communications on to the consulting physician as appropriate. With the exception of deposing the consulting physician if necessary and except as provided in this subdivision, neither party nor a party's attorney, shall communicate directly with nor send correspondence or records directly to the consulting physician.

NOTE: Form referred to above is available at no charge by downloading from the web at http://www.dir.ca.gov/dwc/forms.html or by requesting at 1-800-794-6900.


Note: Authority cited: Sections 133, 139.2, 4061, 4062, 4064, 5307.3 and 5703.5, Labor Code. Reference: Sections 3209.3, 4061, 4062, 4062.1, 4062.2, 4064, 4067 and 5703.5, Labor Code.
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Re: Panel QME referrals to other specialties (California)

Postby danpelin on Tue Nov 03, 2009 11:01 am

I think it hinges on what is the meaning of a consulting physician? I am arguing that if the Legislature wanted to give orthopedic or PMR PQME's the right to control your case by sending the applicant to other specialties such as psychology or psychiatry then they would have indicated that once you go to a PQME, the original PQME can refer the applicant to other PQME's of other specialties. Since the Legislature chose "consulting physician" language that would mean they meant something different than another PQME. Therefore, I have argued that the "consulting physician" must mean another physician that is necessary to help the original PQME reach their opinion. For example, in an orthopedic case where the applicant may have rheumatoid arthritus the PQME may need to refer the applicant to an internist prior to providing their opinion. Conversely, I would argue that the orthopedic or PMR PQME should not be referring the applicant for a "consulting physician" appointment with a psychiatrist for a psyche QME evaluation.

If anyone has any case law or further Codes that can clarify this issue, I would appreciate it. Thanks.
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Re: Panel QME referrals to other specialties (California)

Postby postscript2 on Wed Nov 04, 2009 2:56 am

I think you need to back up to the "DENIAL," and the reason thereof. Is it strong enough to hold up at Trial? Was it based upon any "affirmative defenses" or the 6 month psyche defense for employment??? Are there witness and investigations, depositions which would further defend the denial???

Think about this before jumping through PQME hoops. There must be a reason for not agreeing to an AME here...

Although the statutes may say "consulting physician," it is clear that the original PQME must designate any consulting physicians which are outside of his/her specialty. I always construed this to mean other PQME's. Otherwise, we'd be looking at a 4050 eval, NO? AND what if the 2nd PQME defers to a 3rd and so on???

If I were the defense on this, I'd nip this one in the bud. It's already blooming into a full blown flower and the thorns can be sharp. Perhaps a nuisance value settlement would be in order, depending upon the strengths and weaknesses of the case.

On the other hand, if AOE/COE is likely to be found at Trial, do as much as possible to mitigate the damages and provide the benefits to move to closure.

Just my opinion... Good luck,

LCS
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