Do You Know the Rule? Calif. QME Replacements

08 Mar, 2023 Frank Ferreri

                               

Sacramento, CA (WorkersCompensation.com) -- When a need arises to replace a qualified medical evaluator in California, how is such a replacement requested? 

The following information breaks down the process. 

 
Topics 
Requirements 
When a replacement can happen 
A replacement QME to a panel, or at the discretion of the Medical Director a replacement of an entire panel of QMEs, shall be selected at random by the Medical Director and provided upon request whenever any of the following occurs: 

(1) A QME on the panel issued does not practice in the specialty requested by the party holding the legal right to request the panel. 

(2) A QME on the panel issued cannot schedule an examination for the employee within ninety (90) days of the initial request for an appointment, or if the 90-day scheduling limit has been waived, the QME cannot schedule the examination 120 days of the date of the initial request for an appointment. 

(3) The injured worker has changed her residence address since the QME panel was issued and prior to date of the initial evaluation of the injured worker. 

(4) A physician on the QME panel is a member of the same group practice. 

(5) The QME is unavailable. 

(6) The evaluator who previously reported in the case is no longer available. 

(7) A QME named on the panel is currently, or has been, the employee's primary treating physician or secondary physician. 

(8) The claims administrator, or if none the employer, and the employee agree in writing, for the employee's convenience only, that a new panel may be issued in the geographic area of the employee's workplace and a copy of the employee's agreement is submitted with the panel replacement request. 

(9) The Medical Director, upon written request, finds good cause that a replacement QME or a replacement panel is appropriate for reasons related to the medical nature of the injury. “Good cause” is defined as a documented medical or psychological impairment. 

(10) The Medical Director, upon written request, filed with a copy of the Doctor's First Report of Occupational Injury or Illness and the most recent DWC Form PR-2 (“Primary Treating Physician's Progress Report” or narrative report filed in lieu of the PR-2, determines after a review of all appropriate records that the specialty chosen by the party holding the legal right to designate a specialty is medically or otherwise inappropriate for the disputed medical issues. The Medical Director may request either party to provide additional information or records necessary for the determination. 

(11) The evaluator has violated section 34 (Appointment Notification and Cancellation) of Title 8 of the California Code of Regulations, except that the evaluator will not be replaced for this reason whenever the request for a replacement by a party is made more than 15 calendar days from either the date the party became aware of the violation or the date the report was served by the evaluator, whichever is earlier. 

(12) The evaluator failed to meet the deadlines specified in Labor Code section 4062.5 and section 38 (Medical Evaluation Time Frames) of Title 8 of the California Code of Regulations and the party requesting the replacement objected to the report on the grounds of lateness prior to the date the evaluator served the report. A party requesting a replacement on this ground shall attach to the request for a replacement a copy of the party's objection to the untimely report. 

(13) The QME has a disqualifying conflict of interest. 

(14) The Administrative Director has issued an order pursuant to section 10164(c) of Title 8 of the California Code of Regulations (order for additional QME evaluation). 

(15) The selected medical evaluator, who otherwise appears to be qualified and competent to address all disputed medical issues refuses to provide, when requested by a party or by the Medical Director, either: A) a complete medical evaluation or B) a written statement that explains why the evaluator believes he is not medically qualified or medically competent to address one or more issues in dispute in the case. 

(16) The QME panel list was issued more than 24 months prior to the date the request for a replacement is received by the Medical Unit, and none of the QMEs on the panel list has examined the injured worker.  

Tolling 
Whenever the Medical Director determines that a request for a QME replacement or QME panel replacement is valid, the time limit for an unrepresented employee to select a QME and schedule an appointment and the time limit for a represented employee to strike a QME name from the QME panel shall be tolled until the date the replacement QME name or QME panel is issued. 
Two names struck 
In the event the parties in a represented case have struck two QME names from a panel and subsequently a valid ground arises to replace the remaining QME, none of the QMEs whose names appeared on the earlier QME panel shall be included in the replacement QME panel. 
Form required 
Form 31.5 shall be used to request a replacement QME 

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    About The Author

    • Frank Ferreri

      Frank Ferreri, M.A., J.D. covers workers' compensation legal issues. He has published books, articles, and other material on multiple areas of employment, insurance, and disability law. Frank received his master's degree from the University of South Florida and juris doctor from the University of Florida Levin College of Law.

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