QME exam
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Holds authority to appoint physicians as
Administrative Director (AD) (LC 139.2)
QME evaluators
Term of appointment as QME evaluator 2 years (LC 139.2)
(1) Pass the QME competency exam;
(2) Complete a 12-hour course in disabil-
ity eval report writing;
3 requirements when seeking appoint- (3) Devote at least 1/3rd of total prac-
ment as QME tice time to providing direct medical treat-
ment (or have served as a AME on 8+
occasions in past 12 mos prior to appli-
cation)
(1) Licensing board suspends/re-
2 reasons for termination/suspension of vokes/terminates license to practice
a QME w/o a hearing (2) Failure to pay required fee (upon ap-
pointment and yearly thereafter)
(1) Violation of material statutory or ad-
ministrative duty;
(2) Failure to follow medical procedures
or qualifications;
(3) Failure to comply with the timeframe
standards;
(4) Failure to meet licensing/certification
requirements;
6 reasons for discipline (suspension/ter-
(5) Preparation of medical-legal evalua-
mination) of QMEs after a hearing
tions that fail to meet the minimum stan-
dards for those reports as established by
the administrative director or the appeals
board;
(6) Making material misrepresentations
or false statements in an application for
appointment or reappointment as a qual-
ified medical evaluator.
(1) Compensability of the claim;
(2) Permanent disability;
3 types of substantive medical disputes
(3) "Catch-all" (temporary disability, work
resolved by QMEs
restrictions, new and further disabilities
after permanent disability (detereoration
, QME exam
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of original injury), compensability of new
body part added to claim)
(1) An injury or disease arising out of
employment;
(2) A *derivative* injury caused by treat-
Definition of *injury* in compensability ment of an injury arising out of employ-
claims ment;
(3) Any reaction to or side effect from pre-
ventative health care the employer pro-
vides to health care workers
Occurs as the result of a single incident
*Specific injury*
or exposure
Results from repetitive trauma (mental or
*Cumulative injury*
physical) over a period of time
2 requirements for a condition to be con- (1) Cause disability; or
sidered an injury (2) Result in a need for medical treatment
Disease that in whole or part is caused
Occupational disease
by work
(1) Caused by employee's use of alcohol
or illegal controlled substances;
(2) Intentionally self-inflicted injuries;
(3) Suicide;
(4) Resulting from altercations, in which
the injured employee is the *initial physi-
cal aggressor*;
(5) Resulting from the employee's com-
mission of a felony, for which the em-
7 types of excluded injuries ployee has been convicted (including
"wobbly felonies," which are crimes that
may be prosecuted as misdemeanors or
felonies)
(6) Resulting from off-duty recreational
activities, in which participation in the
activities does not constitute part of the
employee's work-related duties and the
activity is not an expressed or implicit
condition of employment;
, QME exam
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(7) Psychiatric injuries claimed after no-
tice of termination/layoff unless certain
conditions exist
(1) *Injury* (physiological or psychologi-
cal harm);
(2) Employment relationship;
4 basic conditions to establish a workers' (3) Injury caused by the employment
compensation claim (This is also referred to as arising out of
employment [AOE].);
(4) Occurred in the course of the employ-
ment (COE)
(1) Causes a temporary or permanent
increase in disability;
Aggravation of a pre-existing, non-indus- (2) Creates a new need for medical treat-
trial condition ment; or
(3) Requires a change in the existing
course of treatment
*Flare-ups* or *recurrence* of a previ-
Symptoms that don't constitute a new
ous industrial injury or illness; not been
injury
caused by the current employment
Date on which the incident or exposure
Date of injury (DOI)-specific injury
occurred
Date when the employee first suffered
disability from the exposure, and either
Date of injury (DOI)-cumulative injury knew, or should have known, that the dis-
ability was caused by present or previous
employment
(1) Statute of limitations for particular
procedures within the workers' compen-
sation system;
(2) Regulations that will apply to the
Items determined by the DOI worker's injury;
(3) Compensation rate for the worker's
injury;
(4) Employers who are liable for the
claim.
Reasonable medical probability
Study online at https://quizlet.com/_527ff4
Holds authority to appoint physicians as
Administrative Director (AD) (LC 139.2)
QME evaluators
Term of appointment as QME evaluator 2 years (LC 139.2)
(1) Pass the QME competency exam;
(2) Complete a 12-hour course in disabil-
ity eval report writing;
3 requirements when seeking appoint- (3) Devote at least 1/3rd of total prac-
ment as QME tice time to providing direct medical treat-
ment (or have served as a AME on 8+
occasions in past 12 mos prior to appli-
cation)
(1) Licensing board suspends/re-
2 reasons for termination/suspension of vokes/terminates license to practice
a QME w/o a hearing (2) Failure to pay required fee (upon ap-
pointment and yearly thereafter)
(1) Violation of material statutory or ad-
ministrative duty;
(2) Failure to follow medical procedures
or qualifications;
(3) Failure to comply with the timeframe
standards;
(4) Failure to meet licensing/certification
requirements;
6 reasons for discipline (suspension/ter-
(5) Preparation of medical-legal evalua-
mination) of QMEs after a hearing
tions that fail to meet the minimum stan-
dards for those reports as established by
the administrative director or the appeals
board;
(6) Making material misrepresentations
or false statements in an application for
appointment or reappointment as a qual-
ified medical evaluator.
(1) Compensability of the claim;
(2) Permanent disability;
3 types of substantive medical disputes
(3) "Catch-all" (temporary disability, work
resolved by QMEs
restrictions, new and further disabilities
after permanent disability (detereoration
, QME exam
Study online at https://quizlet.com/_527ff4
of original injury), compensability of new
body part added to claim)
(1) An injury or disease arising out of
employment;
(2) A *derivative* injury caused by treat-
Definition of *injury* in compensability ment of an injury arising out of employ-
claims ment;
(3) Any reaction to or side effect from pre-
ventative health care the employer pro-
vides to health care workers
Occurs as the result of a single incident
*Specific injury*
or exposure
Results from repetitive trauma (mental or
*Cumulative injury*
physical) over a period of time
2 requirements for a condition to be con- (1) Cause disability; or
sidered an injury (2) Result in a need for medical treatment
Disease that in whole or part is caused
Occupational disease
by work
(1) Caused by employee's use of alcohol
or illegal controlled substances;
(2) Intentionally self-inflicted injuries;
(3) Suicide;
(4) Resulting from altercations, in which
the injured employee is the *initial physi-
cal aggressor*;
(5) Resulting from the employee's com-
mission of a felony, for which the em-
7 types of excluded injuries ployee has been convicted (including
"wobbly felonies," which are crimes that
may be prosecuted as misdemeanors or
felonies)
(6) Resulting from off-duty recreational
activities, in which participation in the
activities does not constitute part of the
employee's work-related duties and the
activity is not an expressed or implicit
condition of employment;
, QME exam
Study online at https://quizlet.com/_527ff4
(7) Psychiatric injuries claimed after no-
tice of termination/layoff unless certain
conditions exist
(1) *Injury* (physiological or psychologi-
cal harm);
(2) Employment relationship;
4 basic conditions to establish a workers' (3) Injury caused by the employment
compensation claim (This is also referred to as arising out of
employment [AOE].);
(4) Occurred in the course of the employ-
ment (COE)
(1) Causes a temporary or permanent
increase in disability;
Aggravation of a pre-existing, non-indus- (2) Creates a new need for medical treat-
trial condition ment; or
(3) Requires a change in the existing
course of treatment
*Flare-ups* or *recurrence* of a previ-
Symptoms that don't constitute a new
ous industrial injury or illness; not been
injury
caused by the current employment
Date on which the incident or exposure
Date of injury (DOI)-specific injury
occurred
Date when the employee first suffered
disability from the exposure, and either
Date of injury (DOI)-cumulative injury knew, or should have known, that the dis-
ability was caused by present or previous
employment
(1) Statute of limitations for particular
procedures within the workers' compen-
sation system;
(2) Regulations that will apply to the
Items determined by the DOI worker's injury;
(3) Compensation rate for the worker's
injury;
(4) Employers who are liable for the
claim.
Reasonable medical probability
