The QME Process:
How to Successfully Request a Represented Panel
QME Webinar questions and answers
Q: We understand that the emergency QME regulations are in effect through October. Under these emergency regulations, we are to use Forms 105a and 106a, for dates of injury on or after January 1, 2013. The question is when do the final Forms 105 and 106 become effective? There are several questions about this.
A: Thank you, Dr. Das. I didn’t speak earlier, and the forms will be in effect October 1, 2013. The regulations are now in effect, but you do not have to use the new forms until October 1, 2013. And they will be posted on the DWC website today.
Q: Thank you, Karen. Second question is about timelines. Can you talk about the timeline where the fifteenth date from the objection falls on a weekend or a holiday?
A: Sure. The first day is the … the 15 days start after the date of the written objection letter. So, for example, if the objection letter is dated March 10, 2013, the first day is going to be March 11, 2013, and it’s going to be 15 calendar days. So if the 15th day falls on a Saturday, Sunday, or a holiday then it’s going be the … then you’ll count the next business day. The 16th day will be the day after the holiday or weekend.
Q: Can people use the calculator that you mentioned, Kathy, to figure out which day it’s due?
A: We really encourage them to use the date calculator because it considers all holidays that the state has.
Q: Thank you. The third question is, is the QME 106 form required for all dates of injury, in other words, both pre- and post-January 1, 2013?
A: Yes. That makes it very easy. You don’t have to worry about which form for which date of injury.
Q: All right, here’s a simple question. Do you accept electronic signatures?
A: We are accepting them on request forms that come in now.
Q: One of the questions is about the availability of this presentation, and the questioner asks if a copy of this presentation is available as a paper copy.
A. As we mentioned, the webinar as well as the power point will be available on the DWC website shortly after the presentation. We aren’t providing paper copies, but you’re certainly welcome to print it out from the website.
Q: All right. Here’s the next question. What if I need a panel QME to address permanent disability and other non-medical treatment issues? Should I check both 4061 and 4062, or should I send two separate panel QME requests?
A: We recommend that you select only one box and under the dispute box, list the different types of disputes.
Q: Thank you, Karen. Does the doctor named on the dispute letter have to be the primary treating physician or can it be any physician?
A. Regulation 30(b) specifies it be the primary treating physician.
Q: Thank you, Kathy. Can our law firm use its own proof of service or are we required to use the one in Form 106?
A. Form 106 is in regulation, all four pages. You must use those forms and you must not alter those forms.
Q: Thank you. Will the Division allow for a grace period in using the new forms?
A. We will allow a grace period until October 1 in using the new forms.
Q: OK, thank you. Here’s another question. In the sample dispute letter, the doctor was not identified as the primary treating physician. You indicated that the letter must also indicate that the doctor is the primary treating physician. Can you please clear up that discrepancy?
A: That was very good of you to pick that up. What you didn’t see was the dispute letter we had that based that request form actually told us that information. So oftentimes the dispute letter supplements what you have on the request form.
Q: Thank you, Kathy. The next question is – is there an opportunity for a non-represented injured worker to choose a non-panel QME or any QME in relation to an evaluator associated with the Medical Unit?
A: That seems like a … we don’t quite understand that question. Dr. Das, would you mind repeating that question?
Q: All right. I’ll read it the way I’m seeing it here. Is there an opportunity for a non-represented injured worker to choose a non-panel QME or any QME in relation to an evaluator associated with the Medical Unit or workers’ comp appeals board? If so, how, and in what form? I just want to mention that this question is about unrepresented injured workers, and we’re not focusing on that here.
A. So first, an unrepresented injured worker must request a panel using the QME 105 form. We don’t issue non-QME panels because we only certify QMEs. The only opportunity for a non-represented injured worker to select a QME other than through the panel process is if the Medical Unit is not able to meet its statutory timeline for issuing the panel.
Q: Thank you. Here’s another question. Defendants and applicants submit requests on the same date with a different specialty designation. Which one does the medical unit use?
A: We’ll have your answer shortly. If we have two request forms received on the same date, we actually defer that to a physician on site to make that determination.
Q: How can I dispute the medical specialty selected by the opposing counsel?
A: After a panel has been issued, you can file a QME form 31.5 and elect 31.5(a)(10). Be sure to attach a copy of the treating physician’s report and your reason to support the specialty change, stating that the medical dispute is in the case. The medical director will review the medical records and your request in consideration of a specialty change. If it’s found that the scope of the specialty selected can address the dispute issue, the specialty remains unchanged and both parties will be informed of that decision.
Q: Thank you. A questioner wants to know where the date calculator is located.
A: It is at www.datecalculator.com.
Q: Thank you. What if the PTP (primary treating physician) is disputed, in other words, not in the MPN?
A: Dr. Das, I’m sorry. I must correct my last answer. The deadline calculator is actually at deadlinecalculator.com. My apologies.
Q: Thanks for that correction, Kathy. The next question was about if the primary treating physician is disputed, in other words, not in the MPN.
A: As mentioned previously, any disputes regarding the MPN should be resolved before requesting a panel.
Q: Thank you. Here’s a question. Why does it take eight months for a represented applicant to get a panel and only 30 days for the unrepresented applicant to get a panel?
A. Senate Bill 863 made some modifications to the regulations and the statutory timeline for a represented – I mean unrepresented – injured workers. It extended that timeline from 15 working days to 20 working days and gave a preference to issuing panels to unrepresented injured workers. So when there are available resources we also work on represented injured worker panels. We actually work on them at the same time, but the preference is given to unrepresented injured workers. Currently the Medical Unit does have a backlog, but that backlog is five months, and we are working very diligently to decrease and eliminate that backlog. It’s a very high priority for the Division, the highest priority at this point. The end result … the solution that will resolve this problem ultimately will be an electronic solution and we are already working on the path to start that electronic solution. Now bear in mind it takes a little while, so it’s not something that will be available to the community immediately, but we are working very diligently down that path.
Q: Thank you, Kathy. What further explanation is required when the applicant has previously requested a panel QME or has been seen by an AME or QME? I’ll repeat the question. What further is required when the applicant has previously requested a panel QME or has been seen by an AME or QME?
A. So those requests for additional panels and specialties are coming from the AME or QME because these are issues that are outside of their area of clinical specialty, and that’s actually defined in their medical report. If that is submitted on the optional … on what used to be called the optional form 31.7, the form plus the medical report are reviewed and if there is an evaluation necessary, an additional panel will issue in the requested specialty. If the recommendation is for treatment, that would not be a specialty request that we [honor?]. The other method to get an additional panel for this reason would be for the parties to submit a joint letter that they agree that there is an additional specialty panel that needs to issue.
Q: Thank you, Kathy. Can we still request a QME panel for injury dates before January 1, 2013 where the dispute has to do with a utilization review denial done this year, for example, April 2013?
A: Yes, they can. And as long as the UR determination that delayed the treatment is issued before July 1, 2013.
Q. Thank you. If we receive a rejection letter that says our panel form was submitted prematurely, do we simply resubmit the request for just that issue or will you review it again for compliance on other issues, such as 30b?
A. Your request will be reviewed for compliance in meeting the requirements within 30b. Please make sure to review your request for compliance before resubmitting it. This is your perfect opportunity to correct those inconsistencies.
Q: Thank you. We have a couple of questions about this. How should an attorney respond to the question regarding a prior AME or panel QME if they don’t know if that’s been done?
A. If they don’t know if there was a prior AME or QME, they can leave it blank.
Q: Why can’t we have the QME address all our needs as opposed to using the QME process for some items and then IMR process for another?
A: This is a legislative change. Senate Bill 863 created an express lane for applicants to resolve a utilization review decision that delays, modifies or denies a treatment request made by the treating physician while the QME process still applies for those disputes that fall under Labor Code §§4060, 4061 and 4062 that are involving nonmedical treatment disputes with the exception being applicants’ rights to a panel QME for a UR denial of care for the date of injury before January 1, 2013 where the utilization review decision was made before July 1, 2013.
Q: Thank you. Can a defense attorney request a QME evaluation on a worker who has not become permanent and stationary from the primary treating physician or any other doctor they are seeing?
A: We’re working on a response. Can you repeat the question, please?
Q: Sure. Can a defense attorney request a QME evaluation on a worker who has not become permanent and stationary, can the evaluation be requested from the primary treating physician or any other doctors her or she is seeing?
There seems to be some confusion about the question. Maybe we’ll move on to the next question.
A: Dr. Das, we’re coming up on three o’clock, perhaps one last question, please.
Q: Sure. There are a lot of great questions, and I’ve had to select from among them. Here’s the last question. If a panel issues over the objection by the non-representing party, what avenue of redress does the objecting party have to challenge the panel?
A: That’s going to be an issue that has to be addressed at the appeals board level.