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  1. #1
    Join Date
    Nov 2008
    Location
    California
    Posts
    35

    Question What Happens After the QME?

    My workers compensation claim was made in the State of: California.

    I had my QME (Utilization Review Board (UR) denied discography) yesterday and it went well. The QME said she would recommend the discography and now I'm just waiting for it to be put in writing. My understanding is that if the UR denies a procedure, I get a QME and if the QME agrees with the doctor's recommendation, then I can get the discography. But what are the details of the next process? After I get the report, does my doctor just schedule the discography or is there still another battle? Also, the purpose of the disco is to determine whether I'm a candidate for Artficial Disc Replacement (ADR). I already know that ACOEM Guidelines does not approve ADR (and I don't want fusion), however the doctor said she would also recommend ADR. IF the disco shows I'm an ADR candidate and the doctor requests ADR, does (UR) still get to deny the request and will have I have to get another QME even if the one I had yesterday said she would recommend ADR?

  2. #2
    Join Date
    Oct 2006
    Posts
    9,109

    Default Re: What Happens After the QME? (CA)

    The carrier can still take the issue to the work comp court. Without knowing the issues and evidence that likihood can't be predicted.
    If ADR is recommended it is highly likely the carrier will challenge the evidence based medical documentation that would have to be used to support such a treatment recommendation.
    In litigated cases the court generally prefers that the parties arrange for an Agreed Medical examiner to determine medical issues although overturning the ACOEM guidelines is really a legal issue.
    It would most probably have to be adjudicated before the WCAB and on up to the district court of Appeals.

  3. #3
    Join Date
    Feb 2007
    Location
    Calif
    Posts
    18,021

    Default Re: What Happens After the QME? (CA)

    My understanding is that if the UR denies a procedure, I get a QME and if the QME agrees with the doctor's recommendation, then I can get the discography. But what are the details of the next process? After I get the report, does my doctor just schedule the discography or is there still another battle?
    After the PQME report issues, your PTP submits a PR-2 to the CA, including the language "(treatment) requested per Dr PQME report dated....).
    The CA can then approve as requested, or file a DOR for expediated hearing to dispute the findings.

    Also, the purpose of the disco is to determine whether I'm a candidate for Artficial Disc Replacement (ADR). I already know that ACOEM Guidelines does not approve ADR (and I don't want fusion), however the doctor said she would also recommend ADR. IF the disco shows I'm an ADR candidate and the doctor requests ADR, does (UR) still get to deny the request and will have I have to get another QME even if the one I had yesterday said she would recommend ADR?
    You should be ready for a denial to the ADR....disk replacement as you said is not approved as ''medically necessary'' or ''reasonable'' on an industrial basis.
    Even IF the PTP/PQME can provide EBM to substantiate the ADR on any basis, the treatment/ADR STILL must be deemed ''reasonable''...and it reality, IF the fusion would suffice...that is what will be authorized....because it IS reasonable.
    What you want, and/or what your doctor reccommend isn't necessarily the treatment appropriate on an industiral basis..

    And...IF the ADR is denied...and you refuse the treatment/fusion as determined reasonable...your benefits could be stopped...for refusing treatment as reccommended to ''cure and/or relieve''....

    In litigated cases the court generally prefers that the parties arrange for an Agreed Medical examiner to determine medical issues although overturning the ACOEM guidelines is really a legal issue.
    No telling were that comes from...
    The very reason the labor code was changed is for the benefit of the parties to expediate the process...PQME's and AME's, and no more "dueling QME'".
    What the 'court' DOES prefer is for the parties to resolve their disputes informally...through use of the system in place. With the hope of not using the judges to settle the dispute.

    The laws (section 4062) require where the IW is unrepped, a PQME to be used to settle a disputed mediacal issue.

    The laws also require where the IW is repped, a AME be used.
    And I noticed on another post (emiko) that there is some confusion on your part to the AME process. IF the parties cannot agree on the selection of an AME...(first) THEN the medical unit will provide the names of 3 PQME's for each party to scratch a name.

    In Calif...a PQME is contracted/certified by the DWC Medical Unit...but an AME does not have to be a QME...any doctor agreed upon by the parties can function as an AME.

    While not everyone adheres to the labor code in the Disputed Medical Issue process...depending on whether you are in So/No Calif, as long as the system works to the betterment, and expeditious treatment of the IW...that it the process to will prevail. No. So. and San Diego each have their own quirks to the process.

  4. #4
    Join Date
    Nov 2008
    Location
    California
    Posts
    35

    Default Re: What Happens After the QME? (CA)

    1. How did you do the sectioned quotes?

    Note: We're self-insured, have a 3rd party claims administrator (CA) with UR and MPN.

    [/QUOTE]You should be ready for a denial to the ADR....disk replacement as you said is not approved as ''medically necessary'' or ''reasonable'' on an industrial basis.[/QUOTE]

    I have a copy of the ACOEM Guidelines and I already know that the ADR will be denied. I just wasn't sure whether it made a difference if the recommendation came from my dr. or the QME.

    [/QUOTE] And I noticed on another post (emiko) that there is some confusion on your part to the AME process. IF the parties cannot agree on the selection of an AME...(first) THEN the medical unit will provide the names of 3 PQME's for each party to scratch a name.[/QUOTE]

    This is true if I have any attorney (LC 4062.2), but since I haven't hired an atty (LC 4062.1 http://www.leginfo.ca.gov/cgi-bin/di...file=4060-4068 ) yet my CA is supposed to send me a form to request a QME (she didn't, so I downloaded the form myself and submitted it). When I got the list of 3, I was able to pick the one I wanted, I scheduled the appt and had the exam. This is why I haven't hired an atty yet.

    Another question:
    I know the CA/employer has 10 days to object to my dr. request for spinal surgery, but how much time does the CA/Employer have (if any) to file adjudication of claim?
    If the CA files for adjudication and I still havent hired an atty, then they have to pay for the atty (LC 4064c). Therefore, should I wait until the file before hiring an atty?

    Note: the QME was for a discography, but she said she would recommend ADR.

    Phase 2: Spinal surgery:

    Does it make a difference if the QME recommends spinal surgery or do we go back to the beginning where my dr. would request it and CA (actual Utilization Review (UR) board would deny it?

    If the dr. requests it, then I'll have to get a second opinion. LC 4062a says if I do have an atty then the CA and my atty would try to come to an agreement on an ortho surgeon for a 2nd opinion. However, if I don't have an atty, then the state's Administrative Director would randomly select the dr. for the 2nd opinion. Since there are few surgeons in this area that do ADR, they would only be able to recommend fusion; however, I don't want a fusion. So I'll get screwed even if the 2nd opinion approves surgery. Therefore, should I get an atty before the CA denies surgery?

    Seems like timing on when to hire an atty has to be very strategic......

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