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Worker`s Compensation/question about QME report

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QUESTION: I have a foot and ankle injury since 2008. I had an EMG test done then went to see my specialist to discuss test results in 2011. In 2012 went back to specialist to discuss what options, surgery or meds. Surgery outcome didnít sound promising. Specialist final report said success for surgery under WC setting was 30% recovery. He said that he didnít think I was ever going to get better. I was sent again by ins co. to QME in 2012. QME gave me a 6%WPI said ďfor all intense purposes Iím P&S.Ē He mentions future medical because he wanted that available to me if I decide to have surgery in the future. He says injury was work related no apportionment. Sedentary work, no lifting, climbing etc. He was concerned about my ADL.

I received QMEís report in Aug 2012. I waited a little over 20 days to get rating from DEU because former CA sent a letter to me in my QME packet stating the report would go to DEU to be rated. Nothing happened. I called I&A. I was told they only showed something from 2010. That was my first appt with the QME. Iíve seen him 3 times altogether. I explained my situation to I&A. I asked if I could request a supplement be written by the QME since the report hadnít been rated by the DEU. I told her the report said he hadnít received the final report from my specialist or the EMG test results and would like to see them. She said yes. I got the supplement back earlier this month. QME said it didnít change his mind.

I was contacted by CA about supplement. I told her I wanted QMEís report sent to DEU for rating. She said she had an independent rater look at the report and she made an offer. I donít believe her. I told her I would rather have it sent to the DEU because thatís where it was suppose to go originally.

I saw my primary this week and gave him a copy of the supplement. He told me he was going to write his report. Iím assuming he meant a PR4 which he is going to say Iím P&S. I asked him why he needed to do that when I had already seen the QME. He said to tie everything together. I believe my primary was afraid to write his report and thatís why I was sent to the QME. Now it seems like he wants to use the QMEís report to make sure heís in total agreement with him.

The QME has already given me a WPI and said I was P&S and covered everything else. I donít know why I need the primaryís report when the QMEís carries more weight. What would be the purpose to see the QME then?

Does the primary have to release me in order to write a P&S report? He never told me he was going to release me and Iím taking prescription meds. I found out he released me when I looked at my paperwork.

I want to file through EAMS and I was originally going to send only the QMEís report along with his supplement, the final report from the specialist and the EMG results to be rated. Do I need to include my primaryís report along with it if Iím filing it under the heading of Summary rating for a QME report?

Or am I now suppose to file under the heading of Summary rating for doctorís report and include the QMEís report?

ANSWER: YES, the 'definition' of Permament & Stationary means you won't reduce your level of disability with additional treatments... actually, today, when a worker hits their healing 'plateau' the correct term is MAXIMUM MEDICAL IMPROVEMENT.

Your Treating Doc felt you WOULD have less disability with the surgery, so he wasn't afraid, he was waiting to see if you changed your mind or if Utilization Review approved the surgery request.   

When you've declined surgery, all he can do is agree you've reached Maximum Medical Improvement.

QME REPORTS DO NOT 'TRUMP' TREATING PHYSICIAN REPORTS.   In fact the WCAB Judges I know will opt for the treater's findings when all other factors are equal because the treater followed that person for weeks or months or years, but the QME just talked to the worker once.

The form to file with the QME report and your Treating PHysician's final MMI report WAS a ' DEU 200 '.   THE WCAB WEBSITE ERASED IT, so now i must suggest a meeting with the Information & Assistance Officer at the WCAB office where your application is filed.

And if your Application isn't filed, then you need to get a "DEU" number to get those reports filed and rated with the Disability Evaluation Unit.

[I get my ratings by filing a Declaration of Readiness to Proceed to a RATING MSC.  I file those at the WCAB... not the DEU.]

JUST FOR THE QME REPORT YOU ALREADY POSSESS, Try using THIS form:   http://www.dir.ca.gov/dwc/FORMS/EAMS%20Forms/DEU/DEU101.pdf

later, when the Treating Doc's MMI report arrives, send it to the DEU with THIS form:  http://www.dir.ca.gov/dwc/FORMS/EAMS%20Forms/DEU/DEU102.pdf

So THE ANSWER IS: YES file for that Summary rating, but one form for the QME and a different form for the Treating Physician.

The next answer is NO you don't have to be 'released' to be found to be Permanent & Stationary / Maximum Medical Improvement .   You can see the treating physician for medication refills and acupuncture referrals for life, and still be found to have hit your 'healing plateau' .

 
The purpose of seeing the QME is for the judge to see whether you were 'cheated' out of a necessary surgery by an unreasonable Utilization Review doc.   When a Primary Treater requests surgery and UR Doc 'non-certifies' the request, the QME is supposed to consider the treater's request and denial and write an independent report about whether ACOEM says you can really improve with the requested procedure or not.

If were the adjuster, I'd have sent you to a QME too, just so the judge didn't try to do it 6 months later.

TWO REPORTS ARE ADMISSIBLE AT TRIAL:  the treating physician and the QME.   If you and the insurer come up with resolution you both want, the judge WILL want to see both the Treater's MMI report and the QME report before approving any settlement.

Since you're stumbling through this with no attorney (unadvised...remember President Lincoln's admonishment that he who represents himself has a fool for a client!), I'd strongly suggest attending the free Injured Worker workshop nearest you... HERE'S THE LINK TO THE FREE WORKSHOPS:   http://www.dir.ca.gov/dwc/Workshop/Workshop_English.htm


---------- FOLLOW-UP ----------

QUESTION: Thank you for your response. Iím sorry it took so long for me to reply. My computer went down the day after I wrote to you. I just got it back yesterday and spent the day reinstalling everything.

The QME filed his report with the DEU for this injury back in early 2010 when I saw him for the 1st time in late 2009. When he sent his report in 2010 stating I wasnít MMI, I received a letter from the DEU and noticed DEU # and EAMS #. So Iím assuming this is the number I need to use?

I have form 101 already printed out for the QME. Thank you anyway for the link. I have and will be in touch again with I&A soon.

To clarify about sending the QME and PTP reports. What you are saying is that I also need form 102 for the PTP report. In stead of sending them separately can I file them altogether only separating them with forms 101 & 102? Or do these reports have to be filed separately? I waiting for the PTP report to be transcribed and sent to the CA. I have already asked her for a copy when she gets it. Sheís very uncooperative and Iíve already made 2 complaints to her supervisor. Iíll probably file a complaint with the audit unit.

Question about the doctor. Since he released me unexpectedly are you saying I can I go to another doctor at this time or am I supposed to go back to see him? Since he released me is the insurance co still obligated to cover the cost of seeing a doctor, mileage etc since my case hasnít been rated or settled at this time? Iím asking because you mentioned lifetime medical. Am I entitled to lifetime medical right now?

Answer
There is 'No Such Animal' as "lifetime medical".  It's an Urban Myth.

There is the right to FIGHT OVER possible future medical treatment requests for life.   No, you are NOT 'entitled' to 'lifetime medical'.

Regarding Ratings:    ONE FORM is used by the Disability Evaluation Unit for a Treating Physician's MMI findings.   If you elect to get the TREATER'S rated, DEU wants you to use Form DEU102.    JUST THAT form sent with the Treater's report is ONE filing.

THEN, if you elect to get the QME Report rated, DEU101 is the form (with a copy of the QME report) for that.

You mish-mash them up, you'll get the reports mailed back.  

REGARDING A NEW TREATING DOCTOR:   Presuming both the QME and the Treating physician wrote there will be need for treatment for flare-ups and pain management, Labor Code 4600 lets you chose any appropriate MPN Physician... elect this as the new MPN Primary Treating PHysician in writing, put the demand to have the adjuster authorize thia in a fax to the adjuster.

If this new MPN PHysicians says there is some form of treatment you need now, and he issues a Request For Authorization and the UR evaluator agrees it falls within ACOEM Guidelines, you get some more treatment.

If not, you get nothing.  Most people get nothing. They cannot overcome the UR ' non-certified ' determination.

Thank your State Senators and ASsemblymen.   They decided it was fine that injured workers don't get any care once being released; these jerks were re-elected.

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Nancy Wallace

Expertise

California injured workers employed by state and private agencies (NOT federal employees) regarding On-The-Job injuries, disability payments, and terminations from being injured on the job (work-related wrongful terminations).

Experience

20+ years in California Workers Compensation law practice in California. Certified Specialist, Workers' Compensation, Board of Legal Specialization, State Bar of California

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California State Bar Board of Legal Specialization

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Editor, Western State University College of Law newspaper www.Avvo.com www.imhurt.info

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J.D., Western State University College of Law B.S., cum laude, Cal Poly Pomona

Past/Present Clients
Senior adjuster for one county sent me her husband when they needed caring representation. The injured Employment Development Dept. hearing representative -- who see all applicant's attorneys in the region -- hired me when she got hurt on the job. A Fire Department Chief in Orange County came all the way to San Bernardino for my representation.

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