Wednesday, September 11, 2013

We Don't Need Education, We Need Simplification

Something is horribly wrong with a system where professional participants fail a prescribed procedure up to 90% of the time.

The California Division of Workers' Compensation is holding training for claims administrators, attorneys and others to learn how to request a qualified medical evaluator panel.

The reason, according to their press release, is because since the start of 2013, i.e. the start of the changes implemented by SB 863, up to 90% of panel QME requests in represented cases have been improperly submitted, DWC says.

Are we professionals in work comp really THAT stupid?

Or is the system ridiculously overbearing, complex, and silly?

Honestly - why does getting some random doctor have to be so confusingly difficult that it is done incorrectly up to 90% of the time compelling the DWC to educate the professional population?

And, probably related, why is this system still manual?

Here's what's supposed to happen:

1) parties have a dispute about disability and some other medically related issues (though not treatment - now that is the purview of Utilization Review and Independent Medical Review); so

2) one of the parties sends a request for a Qualified Medical Examination; and

3) within 10 days (though experience from what I have heard, and which DWC admits, is longer due to back log) three random names are sent to the parties; then

4) each party strikes a name and the QME is selected.

Why is this so difficult?

I'm sure there's various reasons which is what DWC seeks to address in this education.

My point is that it SHOULDN'T be this difficult!

Here's the reality though, as explained by attorney Michael Sullivan in his Sullivan On Comp treatise:

***********Sullivan On Comp section 14.29***********

If a party wishes to request a panel, the request must be submitted on QME form 106 (request for QME panel under LC 4062.2 — represented). A copy of the form may be obtained at the DWC website: The party requesting a QME panel must:
  • Attach a written objection indicating the identity of the primary treating physician, the date of the primary treating physician's report that is the subject of the objection and a description of the medical dispute that requires a comprehensive medical-legal report to resolve.
  • Designate a specialty for the QME panel requested.
  • State the specialty preferred by the opposing party, if known.
  • State the specialty of the treating physician (CCR 30(b)).
QME form 106 specifically requests this information. Page three of the form also contains codes for the various specialties. The completed form must be mailed to the Medical Unit address that is on QME form 106 by first-class mail delivered by the U.S. Postal Service. The Medical Unit will not accept panel requests in represented cases that are delivered in person by a party, the party's attorney, any other person or by other commercial courier or delivery services (CCR 30(g)).

Also, the form specifically requests whether the examination is requested under LC 4060, LC 4061, LC 4062 or LC 4061 and LC 4062. In one case, however, the appeals board held that an applicant's clerical error in requesting a panel QME evaluation under LC 4061 and LC 4062, instead of LC 4060, did not render the assigned panel invalid because the form also stated that the claim was denied. Furthermore, the defendant was sanctioned under LC 5813 for objecting to the evaluation solely on the grounds of this clerical error, and informing the selected panel QME that her report would be inadmissible.[9]

If the request form is incomplete or improperly completed so that a QME panel selection cannot properly be made, the request form will be returned to the requesting party with an explanation of why the QME panel selection could not be made. The medical director also may delay issuing a QME panel, if necessary, until the receipt of additional, reasonable information requested from one or both parties that is needed to resolve the panel request. Reasonable information includes, but is not limited to, whether a QME panel previously issued to the injured worker was used (CCR 30(c)). If the medical director asks a party for additional information needed to resolve the panel request, the periods for selecting an evaluator from a QME panel and for scheduling an appointment will be tolled and will remain tolled until the date the medical director issues either a new QME panel or a decision on the panel request (CCR 30(h)).

If the request form is submitted and the employee no longer resides within California, the geographic area of the QME panel selection within the state will be determined by agreement between the parties. If the parties cannot reach an agreement, the geographic area of the QME panel selection will be determined by the office of the employee's attorney for a represented employee (CCR 30(e)).
***********END Sullivan On Comp section 14.29***********


Though I haven't talked to him in some time, Bryan Nix who used to be Nevada's Chief Administrative Hearing Officer in charge of all administrative adjudicatory bodies, including that state's Workers' Compensation Board, demonstrated how parties are able to get hearings quickly and without undue paperwork or hassle.

The hearing request procedure at the main office in Las Vegas when I last met with him was simply to submit a hearing request on paper - the Nevada WCB didn't require any specific forms; any piece of paper with the case number and request legibly written would generate a hearing.

Why can't we do that in California? Why do we need all of these legal references, all of this redundant information, all of the unnecessary procedure?

No wonder DWC has a back log of QME requests and can not process them timely - it's own staff has to sort through and discriminate requests on the basis of illogical mandates for information.

Please - we don't need education, we need simplification. THAT will solve the QME "problem."

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