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Can Total Temporary Disability checks stop without the final written QME report?
#1
For workers' comp, after a QME exam, before the doctor sends out the written report, are they allowed to call the insurance adjuster to inform them of the findings and can the adjuster cut off Total Temporary Disability checks based on such phone conversations?

I've been on TTD since last fall, and just went to a QME two weeks ago (the insurance company challenged the TTD status by the last treating physician). Since then, I've also been assigned a doctor since the last one dropped out of the MPN. The new doctor also placed me on TTD for another two months. (By the way, if the QME finds me P&S, does that override this new doctor's TTD certification? I am wondering because the QME was to challenge the last doctor's work status report.)

I received an email today from the nurse case manager saying that since I attended the QME, she's closing out the medical management of the claim. I called the QME doctor's office and they said no written reports had been sent out so far. I am very confused, and I can't reach the nurse manager or the adjuster. Truly appreciate any feedback you might have.
 
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#2
each state has separate laws concerning workers comp; without knowing your state a specific answer can't be given

if your are referring to a california claim then the call to the carrier after the exam with advance information on your disability status may be considered "ex parte" communication. the WCAB would ultimately have to make that determination.
Labor Code 4602.3 covers communication with AMEs/QMEs. section (e) seems to limit communication prior to the evaluation. whether there has been improper and substantial communication between the QME offfice and the carrier in violation of the statute in your case is unclear.
"(e) All communications with a qualified medical evaluator selected from a panel before a medical evaluation shall be in writing and
shall be served on the opposing party 20 days in advance of the evaluation. Any subsequent communication with the medical evaluator
shall be in writing and shall be served on the opposing party when sent to the medical evaluator."


while section (j) does require a written report after the exam it does not specifically limit other communication after the exam:

(j) Upon completing a determination of the disputed medical issue, the medical evaluator shall summarize the medical findings on a form
prescribed by the administrative director and shall serve the formal medical evaluation and the summary form on the employee and the
employer. The medical evaluation shall address all contested medical issues arising from all injuries reported on one or more claim forms
prior to the date of the employee's initial appointment with the medical evaluator.


http://www.leginfo.ca.gov/cgi-bin/displa...=4060-4068

were you informed by the QME or their office that you were P&S and not TTD?

Yes, the QMEs opinion takes precedence over other medical opinions unless there has been a major change in your condition since the QMEs exam.

you can file a complaint with the Medical Unit:
"Complaints should either be put in writing and sent to the DWC Medical Unit (Attn: Complaint Unit) P.O. Box 420603, San Francisco, CA 94142, or you can make an anonymous complaint by calling the Medical Unit's hotline at 1-800-999-1041. The Medical Unit prefers to have your name and address or phone number so that it can reach you if there are questions."

http://www.dir.ca.gov/dwc/medicalUnit/faqIW.html

if your claim is in another state the above information does not apply.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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#3
(10-13-2016, 11:43 PM)1171 Wrote: Thank you.  This is most helpful.

I am in CA so this is very useful info.

I am having trouble understanding what "close medical management of your claim" means, especially when the written report has not been sent out (I called the QME office to confirm this.)  Do you happen to know if that's something commonly done once someone's attended a QME appointment?  The nurse case manager simply stated that she would be "closing medical management of your claim" and to refer all future questions to the adjuster.

Thanks again.


each state has separate laws concerning workers comp; without knowing your state a specific answer can't be given

if your are referring to a california claim then the call to the carrier after the exam with advance information on your disability status may be considered "ex parte" communication. the WCAB would ultimately have to make that determination.
Labor Code 4602.3 covers communication with AMEs/QMEs.  section (e) seems to limit communication prior to the evaluation. whether there has been improper and substantial  communication between the QME offfice and the carrier in violation of the statute is unclear.
"(e) All communications with a qualified medical evaluator selected from a panel before a medical evaluation shall be in writing and
shall be served on the opposing party 20 days in advance of the evaluation. Any subsequent communication with the medical evaluator
shall be in writing and shall be served on the opposing party when sent to the medical evaluator."


while section (j) does require a written report after the exam it does not specifically rule out ex parte  communication after the exam:

(j) Upon completing a determination of the disputed medical issue, the medical evaluator shall summarize the medical findings on a form
prescribed by the administrative director and shall serve the formal medical evaluation and the summary form on the employee and the
employer. The medical evaluation shall address all contested medical issues arising from all injuries reported on one or more claim forms
prior to the date of the employee's initial appointment with the medical evaluator.


http://www.leginfo.ca.gov/cgi-bin/displa...=4060-4068

Yes, the QMEs opinion takes precedence over other medical opinions unless there has been a major change in your condition since the QMEs exam.

you can file a  complaint with the Medical Unit:
"Complaints should either be put in writing and sent to the DWC Medical Unit (Attn: Complaint Unit) P.O. Box 420603, San Francisco, CA 94142, or you can make an anonymous complaint by calling the Medical Unit's hotline at 1-800-999-1041. The Medical Unit prefers to have your name and address or phone number so that it can reach you if there are questions."

http://www.dir.ca.gov/dwc/medicalUnit/faqIW.html

if your claim is in another state the above information does not apply.
 
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#4
i suspect it means the nurse is closing out their involvement in the claim.
there is no standard practice on when a nurse case manager stops their activity. it really depends on their contract with the carrier and the adjusters preference. it sounds like they don't believe there is much more for them to do.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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#5
(10-14-2016, 02:32 AM)1171 Wrote: i suspect it means the nurse is closing out their involvement in the claim.
there is no standard practice on when a nurse case manager stops their activity. it really depends on their contract with the carrier and the adjusters preference. it sounds like they don't believe there is much more for them to do.

Thank you for your reply.  It's so kind of you to take time to share.

I got very anxious with her email because she's never emailed me before and it has been so difficult dealing with this insurance company the whole way through.  I didn't get an attorney.  My mom has been helping me.

I had the QME at the end of September.  This past Monday I had to see a new treating physician to continue my work status certification, since the last one dropped out of their MPN (He said he didn't want to work with the insurance company anymore).  The new doctor put me on two months TTD and said she was going to refer me to continue physical therapy.  The insurance picked this new doc, too, so it's very confusing that nurse case manager would be "closing medical management" since obviously I am still needing medical treatment.  The adjuster is on vacation.  I am not hearing back from anyone.  It just makes me wonder if they know something I don't, and is going to cut off my benefits and disapprove treatment.  Makes it very hard to relax and rest, which is what I need.

Sigh.
 
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#6
(10-14-2016, 02:32 AM)1171 Wrote: i suspect it means the nurse is closing out their involvement in the claim.
there is no standard practice on when a nurse case manager stops their activity. it really depends on their contract with the carrier and the adjusters preference. it sounds like they don't believe there is much more for them to do.

I saw that I didn't answer your question directly.  No, the QME doctor has not declared me P&S.  I have not received any reports.  (I don't know what he's going to write, actually.)  When I called the QME office, they confirmed that they did not send any reports out yet to anyone.

It's good to know that the insurance company shouldn't call the QME until the report is done.  Thanks for that bit of info (if I understood ex parte correctly.)
 
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#7
The law doesn't say they can,t call; it just requires a written report.
The fact that the QME gave the carrier information on your status but did not do the same for you works in your favor as far as making your complaint legitimate; especially if you do not know what else was discussed and whether it will change what the doctor puts in the report.
You can request a different QME because of the possible violation. Whether it,ll be granted is unknown. You can Call
The medical unit and follow up with a written complaint.
You can change to any doctor in the MPN at any time; you don,t have to let the carrier choose.the QME opinion still controls.
If they stop the checks before the report is released you can request a penalty. This Would require litigation of the claim with the comp court.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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#8
(10-14-2016, 12:36 PM)1171 Wrote: The law doesn't say they can,t call; it just requires a written report.
The fact that the QME gave the carrier information on your status but did not do the same for you works in your favor as far as making your complaint legitimate; especially if you do not know what else was discussed and whether it will change what the doctor puts in the report.
You can request a different QME because of the possible  violation. Whether it,ll be granted is unknown. You can Call
The medical unit and follow up with a written complaint.
You can change to any doctor in the MPN at any time; you don,t have to let the carrier choose.the QME opinion still controls.
If they stop the checks before the report is released you can request a penalty. This Would require litigation of the claim with the comp court.

Thank you again.

I just called the medical unit, and they said that for a complaint to be filed, I would need to have hard proof that ex parte communication had taken place, either transcripts of phone conversations or copies of email between the doctor and the insurance company.  She suggested that I take it to the appeals board, but I would probably need to provide proof there, too.

This is near impossible.  I really wouldn't be able to know for sure if the QME doctor gave my status to them over the phone, and if so, to have evidence. 

She did tell me that it is unusual for a workers comp case to be assigned a nurse case manager (I've had her since the beginning for a year though, and she has been extremely NOT helpful), and that the medical part of my claim may not be necessarily closed (I hope not as I need more treatment that the new doctor is now referring me to).  It may just be that this particular nurse case manager's involvement is ending, which is what you said also.

I feel so suspicious though at the timing.....just because I went to a QME, why would she all of a sudden close out the management: the new doctor certainly has prescribed more treatments.

Eh.
 
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#9
I don't think you need proof or evidence to file a complaint although it's obvious you will need it to get another QME assigned.
it sounds like they are not interested in doing any investigation themselves. very bogus process if that's all the help they give workers. The medical unit is not a court; they are an administrative agency that's charged with policing the medical process used by the DWC and to me that means looking into complaints when they are notified.
how did you find out the carrier and the QME office discussed your TTD status?
it is not rare for a nurse case manager to be involved in a comp claim. this medical unit person does not seem well informed about the work comp processes. there are any number of separate companies that have contracts with comp carriers and many comp carriers/Third Party Administrators have nurse case managers on their staff.
Dr. Raymond Meister is the head of the Medical unit. you can inform him about the quality of your conversation with his staff. I believe a number of senior managers at the DIR, DWC and the WCAB would not be happy with the lack of seriousness the medical unit treats complaints of ex parte communication.
I would hope that who ever you talked to does not speak for how the medical unit handles the complaint process--basically dumping off an unrepresented worker into the WCAB legal system.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
Reply
#10
(10-13-2016, 11:08 PM)cainjuredworker Wrote: For workers' comp, after a QME exam, before the doctor sends out the written report, are they allowed to call the insurance adjuster to inform them of the findings and can the adjuster cut off Total Temporary Disability checks based on such phone conversations?

I've been on TTD since last fall, and just went to a QME two weeks ago (the insurance company challenged the TTD status by the last treating physician). Since then, I've also been assigned a doctor since the last one dropped out of the MPN. The new doctor also placed me on TTD for another two months. (By the way, if the QME finds me P&S, does that override this new doctor's TTD certification? I am wondering because the QME was to challenge the last doctor's work status report.)

I received an email today from the nurse case manager saying that since I attended the QME, she's closing out the medical management of the claim. I called the QME doctor's office and they said no written reports had been sent out so far. I am very confused, and I can't reach the nurse manager or the adjuster. Truly appreciate any feedback you might have.

I agree with 1171. Unless they faxed your claims adjuster the report and mailed it to you but it sounds like this did not happen.

If you find the QME did P&S you yes the TTD can stop.

Please know the nurse case manager is usually not your friend. You can ask for the medical provider network and pick your own PTP. I recommend checking the report of the new PTP to make sure he did not P&S you. Usually adjusters pick insurance friendly doctors. You can pick your own if you choose.

If you find the adjuster did have ex-parte communication you can file for a hearing and request a new one or contact the medical unit. Either way it sounds like you may need more help than what you can get from a message board. I recommend going in to the work comp board your case is located and sit down with an information and assistance officer about what is going on. They should be able to help you and if not I recommend consulting with a few attorney's. You should file for state disability if your PTP has not deemed you P&S and you file for this on the EDD website and your doctor has to fill out part of the form.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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