Cal. Code Regs. tit. 8 § 11.5

Current through Register 2024 Notice Reg. No. 45, November 8, 2024

Section 11.5 - Disability Evaluation Report Writing Course

Prior to appointment as a QME, a physician shall complete a course of at least sixteen hours of instruction in disability evaluation report writing. The course curriculum shall be specified by the Administrative Director. Only report writing courses which are offered by education providers as defined in subdivision of Title 81(p) of Title 8 of the California Code of Regulations shall qualify to satisfy this requirement.

(a) An education provider applicant shall submit:

(1) a completed QME Form 118 (Application for Accreditation) (see, 8 Cal. Code Regs. § 118) which contains:

(A) the applicant's name; address; director of education with contact information; type of organization; length of time in business; nature of business; and past experience providing continuing education courses (including a list of other accrediting agencies that have approved such courses);

(B) a description of the proposed education program or course which includes the title; type (continuing education program or disability evaluation report writing course); location(s); date(s); length of training in clock hours; educational objectives; a complete description of the program or course content; faculty; and the names of other accrediting agencies that have approved the program.

(2) A curriculum vitae for each proposed instructor. A proposed instructor shall have education and/or training and recent work experience relevant to the subject of his/her or their presentation.

(3) The application for accreditation as an education provider, along with all required supporting documents, shall be submitted to the Administrative Director, at least 60 calendar days before any public advertisement of the applicant's course.

(b) The Administrative Director shall accredit an applicant that: meets the definition of an education provider; submits a completed, signed and dated application which demonstrates past experience in providing continuing education programs; and proposes a program which meets the requirements of section 55(b) or a course which meets the requirements of section 11.5(a) and (i). The applicant must demonstrate that adequate time is allocated to the curriculum set forth in section 11.5(i) for the course to be approved by the Administrative Director. Proposed content for continuing education program credit must relate directly to disability evaluation or California workers' compensation-related medical dispute evaluation. No credit shall be recognized by the Administrative Director for material primarily discussing the business aspects of workers' compensation medical practice, including but not limited to billing, coding and marketing.

(c) The Administrative Director shall notify the applicant within 20 calendar days after receipt of the application containing all the information listed in section 11.5(a) whether that education provider has been accredited for a two year period and the proposed course has been approved. Incomplete applications will be returned to the applicant.

(d) Each education provider that has been accredited by the Administrative Director will be given a number which must be displayed on course promotional material.

(e) On or before the date the course is first presented, the education provider shall submit the program syllabus (all program handouts) to the Administrative Director.

(f) An approved course may be offered for two (2) years. An accredited education provider shall notify the Administrative Director in writing of any change to the faculty in an approved course. The provider shall send the Administrative Director the program outline, promotional material and faculty for each offering of the program at least 45 days prior to the date of the presentation of the program. The Administrative Director may require submission of the program syllabi. The Administrative Director may require changes in the program based on its review of the program outline, program syllabi, promotional material or faculty if the Administrative Director finds that any aspect of the program is not in compliance with these regulations.

(g) To apply for re-accreditation, the education provider applicant must submit a completed QME Form 118 (Application for Accreditation) (see, 8 Cal. Code Regs. § 118), using the application process in 11.5(a). The applicant may complete section 2 of the form using a new program or course or one which was given by the applicant during the recent accreditation period. The Administrative Director shall give the provider 90 days' notice of the need to seek re-accreditation.

(h) Promotional materials for a course must state the education provider's educational objectives; the professional qualifications of course faculty (at the least, all relevant professional degrees); the content of course activities; and the intended audience.

(i) The minimum of 16 hours of instruction in disability evaluation report writing shall include:

(1) The Qualified Medical Evaluator's Role in the Disability Evaluation Process (minimum recommended 1 hour)

How disability evaluation reports are used

The reasons why reports must be clear, complete and timely

The QME's role as an expert witness

Impact of the QME's report on the injured worker

QME ethics and the Confidentiality of Medical Information Act

(2) Elements of the Medical-Legal Report (minimum recommended 1 hour)

The Labor Code and regulatory requirements for medical-legal reports

(3) The Language of Reports (minimum recommended 4 hours)

Evaluation of disability in California (impairment and disability)

The occupational history

The physician examination and the role of testing

The Medical Treatment Utilization Schedule (MTUS) adopted by the Administrative Director pursuant to Labor Code section 5307.27, found in section 9792.20et seq of Title 8 of the California Code of Regulations

Providing opinions that resolve disputed medical treatment issues consistent with the evaluation criteria specified in section of Title 835.5(d) of Title 8 of the California Code of Regulations

Packard Thurber's Evaluation of Industrial Disability, section 43 through 47 and section of Title 89725 through 9727 of Title 8 of the California Code of Regulations (for cases with dates of injury not subject to the AMA guide-based impairment rating system, described below)

Factors of disability, including subjective and objective factors, loss of pre-injury capacity and work restrictions, for cases involving dates of injury not subject to the AMA guide-based impairment rating system

Activities of Daily Living, for cases subject to the AMA Guides

Work restrictions

Work Capabilities

American Medical Association, Guides to the Evaluation of Permanent Impairment, [Fifth Edition] (AMA Guides) and its use in determining permanent disability in accordance with the Schedule for Rating Permanent Disabilities [effective January 1, 2005] (for all claims with dates of injury on or after January 1, 2005, and for those compensable claims arising before January 1, 2005, in which either there is no comprehensive medical-legal report or no report by a treating physician indicating the existence of permanent disability, or when the employer is not required to provide the notice to the injured worker required by Labor Code section 4061)

Causation

Determination of permanent and stationary status

Apportionment including the requirements of Labor Code sections 4660, 4663 and 4664 added by SB 899 (Stats. 2004, ch. 34)

Future medical care

Review of records

Providing sufficient support for conclusions

(4) Instruction in anti-bias training which meets the qualifications outlined in Regulation 11(h) (mandatory minimum of at least 2 hours)

(5) Instruction consisting of a review workers' compensation case law (minimum recommended 2 hours)

(6) The Administrative Director's Disability Evaluation Protocols (minimum recommended 1 hour)

An overview of the Neuromusculoskeletal, Pulmonary, Cardiac, Immunologic, or Psychiatric protocols, and an in-depth discussion of measurement of impairment, calculations and rationale for rating under the AMA Guides, as relevant.

(7) The Third Party Perspective (minimum recommended 1 hour)

The report from the perspective of those who read it:

Judge(s), attorney(ies), insurer(s), rater(s), employer(s), qualified rehabilitation representative(s).

(8) Anatomy of a Good Report (small group or other interactive sessions -- minimum recommended 3 hours)

Discussion of examples of good reports and identification of weaknesses in reports

Opportunities for the practitioner to critique and/or correct reports.

If feasible, physician should have the opportunity to write a sample report.

Review of results of Administrative Director's annual report review and identification of common problems with reports.

(9) Mechanics of Report Writing (minimum recommended 1 hour)

The QME Process

Face to face time

Timelines for submission of report

Completion of required forms

Service of reports

Final questions and answers

(10) Submission and Critique of Written Medical/legal Report. As a condition of completion of the course taken to satisfy the requirements of this section, each physician enrollee shall draft at least one practice written medical/legal report, based on a sample case library of materials, which written report shall be critiqued with notations by the course education provider.

(j) All audio or video tapes, computer programs and printed educational material used in the course must be submitted to the Administrative Director on or before the date the course is first given. Six (6) hours of instruction shall consist of in person or on site lecture, didactic sessions and group discussion. Up to ten hours of instruction may be completed by distance learning whenever the Administrative Director has approved the submitted course prior to the first day the course is given. All distance learning materials shall bear a date of release and shall be updated yearly. The education provider shall notify the Administrative Director in writing of the revision.

(k) No one shall recruit members or promote commercial products or services in the instruction room immediately before, during, or immediately after the presentation of a course. Education providers or vendors may display/sell educational materials related to workers' compensation or applications for membership in an area adjoining a course. A course provider or faculty member shall disclose on QME Form 119 (Faculty Disclosure of Commercial Interest) (see, 8 Cal. Code Regs. § 119) any significant financial interest held by faculty in or affiliation with any commercial product or service which is discussed in a course and that interest or affiliation must be disclosed to all attendees. An education provider shall file every Form 119 in its possession with the Administrator Director.

(l) The provider shall maintain attendance records for each disability evaluation report writing course for a period of no less than three years after the course is given. A physician attending the course must be identified by signature. The provider must submit a copy of the signature list to the Administrative Director within 60 days of completion of the course.

(m) The provider is required to give the QME Evaluation Form 117 (Qualified Medical Evaluator Continuing Education Response Form) (see, 8 Cal. Code Regs. § 117) to course attendees and request they submit the form to the Administrative Director. This information shall not be used in lieu of a certification of completion given by the provider, as specified pursuant to section (n). Destruction by a provider or its employee of a QME's Evaluation Form or failure by such provider or its employee to distribute Form 117 as part of its course shall constitute grounds for revocation of a provider's accredited status. The Administrative Director shall tabulate the responses and return a summary to the provider within 90 days of completion of the course.

(n) The provider shall issue a certificate of completion to the physician that states the name of the provider, the provider's number, the date(s) and location and title of the course. To be eligible for appointment as a QME, a physician must complete no less than 16 hours of the curriculum specified in Section 11.5(i) and must submit a copy of that certificate to the Administrative Director.

(o) Joint sponsorship of courses (as between an accredited and an unaccredited provider) must be approved by the Administrative Director prior to presentation of the course.

(p) The Administrative Director may audit a provider's course(s) at the request of the medical director to determine if the provider meets the criteria for accreditation. The Administrative Director may audit courses given by providers randomly, when a complaint is received, or on the basis of responses on QME Form 117 (Qualified Medical Evaluator Continuing Education Response Form) (see, 8 Cal. Code Regs. § 117). An auditor shall not receive QME credit for auditing a course. The Administrative Director shall make written results of the audit available to the provider no more than 30 days after the audit is completed.

(q) Accredited providers that cease to offer disability evaluation report writing courses shall notify the Administrative Director in writing no later than 60 days prior to the discontinuing an approved course.

(r) The Administrative Director may withdraw accreditation of a provider or deny such a provider's application for accreditation on the following grounds (in addition to failure to meet the relevant requirements of subsections 11.5(a):

(1) Conviction of a felony or any offense substantially related to the activities of the provider.

(2) Any material misrepresentation of fact made by the provider.

(3) Failure to comply with Administrative Director regulations.

(4) False or misleading advertising.

(5) Failure to comply with Administrative Director's recommendations following an audit.

(6) Failure to distribute QME Form 117 (Qualified Medical Evaluator Continuing Education Response Form) (see, 8 Cal. Code Regs. § 117) cards to course attendees.

NOTE: Forms referred to above are available at no charge by downloading from the web at www.dir.ca.gov/dwc/forms.html or by requesting at 1-800-794-6900.

Cal. Code Regs. Tit. 8, § 11.5

Note: Authority cited: Sections 133, 139.2, 4060, 4061, 4062, 4062.1, 4062.2 and 5307.3, Labor Code. Reference: Sections 139.2, 4060, 4061, 4061.5, 4062, 4062.1, 4062.2, 4062.3 and 4067, Labor Code.

Note: Authority cited: Sections 133, 139.2, 4060, 4061, 4062, 4062.1, 4062.2 and 5307.3, Labor Code. Reference: Sections 139.2, 4060, 4061, 4061.5, 4062, 4062.1, 4062.2, 4062.3 and 4067, Labor Code.

1. New section filed 10-16-2000 as an emergency; operative 1-1-2001 (Register 2000, No. 42). A Certificate of Compliance must be transmitted to OAL by 5-1-2001 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 5-2-2001 as an emergency; operative 5-2-2001 (Register 2001, No. 18). A Certificate of Compliance must be transmitted to OAL by 8-30-2001 or emergency language will be repealed by operation of law on the following day.
3. Certificate of Compliance as to 5-2-2001 order, including further amendment of section, transmitted to OAL 7-12-2001 and filed 8-23-2001 (Register 2001, No. 34).
4. Amendment of section and Note filed 1-13-2009; operative 2-17-2009 (Register 2009, No. 3).
5. Amendment of subsection (i)(3) filed 12-31-2012 as an emergency; operative 1-1-2013 pursuant to Government Code section 11346.1(d) (Register 2013, No. 1). A Certificate of Compliance must be transmitted to OAL by 7-1-2013 or emergency language will be repealed by operation of law on the following day.
6. Amendment of subsection (i)(3) refiled 7-1-2013 as an emergency; operative 7-1-2013 (Register 2013, No. 27). A Certificate of Compliance must be transmitted to OAL by 9-30-2013 or emergency language will be repealed by operation of law on the following day.
7. Certificate of Compliance as to 7-1-2013 order, including amendment of first paragraph, transmitted to OAL 8-2-2013 and filed 9-16-2013; amendment operative 9-16-2013 pursuant to Government Code section 11343.4(b)(3)(Register 2013, No. 38).
8. Amendment of first paragraph and subsections (a)(2), (b) and (i), new subsections (i)(4)-(5), subsection renumbering and amendment of subsections (j) and (n) filed 2-26-2024; operative 2/26/2024 pursuant to Government Code section 11343.4(b)(3) (Register 2024, No. 9).