Straight From The Claims Adjusters Mouth

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Medical Quizzes & Trivia

This quiz tests your knowledge as to the California Workers' Compensation laws and processes.


Questions and Answers
  • 1. 
    • A. 

      SB 899

    • B. 

      SB 863

    • C. 

      SB 429

  • 2. 
    The Legislature reinforced the statutory limits on chiropractic care, occupational therapy and physical therapy.
    • A. 

      True

    • B. 

      False

  • 3. 
    The Legislature restricted the use of chiropractors as primary treating physicians. 
    • A. 

      True

    • B. 

      False

  • 4. 
    An employee will be only entitled to no more than 24 chiropractic visits. 
    • A. 

      True

    • B. 

      False

  • 5. 
    If the employer authorizes additional chiropractic treatments in writing, this does not apply to the 24 visit cap. 
    • A. 

      True

    • B. 

      False

  • 6. 
    Labor Code Section 4600 (c) was amended to direct that a chiropractor should not be the treating physician after the employee has received the maximum medical the maximum number of chiropractic visits allowed. 
    • A. 

      True

    • B. 

      False

  • 7. 
    Chiropractors may remain as a primary treating physicians only until the applicant has received 24 chiropractic visits. 
    • A. 

      True

    • B. 

      False

  • 8. 
    • A. 

      July 1, 2013

    • B. 

      July 1, 2014

    • C. 

      July 1, 2015

  • 9. 
    A chiropractor automatically ceases to be the primary treating physician unless the employer provides written authorization for more visits. 
    • A. 

      True

    • B. 

      False

  • 10. 
    CCR 9785 (a) (1) prohibition does not apply to the provision of postsurgical physical medicine prescribed by the employer’s surgeon, or physician designated by the surgeon pursuant to the post-surgical guidelines. 
    • A. 

      True

    • B. 

      False

  • 11. 
    LC 4604.5(c) (3) allows a chiropractor to treat an employee following surgery without those visits being counted towards the 24-visit limit. 
    • A. 

      True

    • B. 

      False

  • 12. 
    CRR 9785 (a) (1) defines a “chiropractic visit” as any chiropractic office visit, regardless of whether the services performed involve chiropractic manipulation or are limited to evaluation and management. 
    • A. 

      True

    • B. 

      False

  • 13. 
    In what year Medical Provider Networks (MPN’s) were authorized by SB899? 
    • A. 

      2000

    • B. 

      2002

    • C. 

      2004

  • 14. 
    Before SB 899, employees did not have free choice to choose a treating physician 30 days after reporting an industrial injury. 
    • A. 

      True

    • B. 

      False

  • 15. 
    A network intended to provide evidence-based treatment for injured workers by offering a panel of physicians developed by the employer. 
    • A. 

      HCN

    • B. 

      MPN

    • C. 

      OPN

  • 16. 
    SB 863, reforms were intended to improve the quality of Medical Provider Networks. 
    • A. 

      True

    • B. 

      False

  • 17. 
    SB 863 strengthened employer control by eliminating the ability of injured workers to treat outside of a network. 
    • A. 

      True

    • B. 

      False

  • 18. 
    Rules enacted by SB 863, has prevents injured workers from treating outside of a network; however others have found ways to treat successfully with non-MPN providers.
    1. True
    2. False
    • A. 

      True

    • B. 

      False

  • 19. 
    • A. 

      LC 4600

    • B. 

      LC4603

    • C. 

      LC4616

  • 20. 
    • A. 

      LC 4616(a)(b)

    • B. 

      LC 4616(b)(2)

    • C. 

      LC 4616(a)(1)

  • 21. 
    Labor Code (LC) section 4616(a)(4) states that a treating physician will be included in an MPN only I, at the time of agreeing or renewing an agreement to be in the MN, the physician or an authorized employee provides a separate written acknowledgment that the physicians elects to be a member of the network. 
    • A. 

      True

    • B. 

      False

  • 22. 
    • A. 

      LC 4616(b)(2)

    • B. 

      LC 4616(b)(3)

    • C. 

      Both A & B

  • 23. 
    In what year, the Regulations regarding the medical access assistant were to promulgated by the administrative director?
    • A. 

      2004

    • B. 

      2012

    • C. 

      2013

  • 24. 
    The administrative director must approved a plan submitted by an employer or insurer for an MPN if requirements of LC 4616 are met.
    • A. 

      True

    • B. 

      False

  • 25. 
    In what year, existing approved plans are deemed approved for four years from the most recent application or modification approval date?
    • A. 

      2004

    • B. 

      2013

    • C. 

      2014

  • 26. 
    The “Clifton Case”, held that a defendant may satisfy it burden of proving it has a properly established MPN by asserting that it has an approved MPN, and requesting judicial notice of the inclusion of its MPN in the list of approved networks on the administrative director’s website. 
    • A. 

      True

    • B. 

      False

  • 27. 
    Following SB 863, applicants can argue that they can treat outside of MPN’s on the grounds that they were formed invalidly. 
    • A. 

      True

    • B. 

      False

  • 28. 
    The administrative director is given the power to make sure that MPN’s run correctly. 
    • A. 

      True

    • B. 

      False

  • 29. 
    Per LC 4616(b)(4), the director is authorized to investigate complaints and to conduct random reviews of approved MPN’s. 
    • A. 

      True

    • B. 

      False

  • 30. 
    Anyone who contends that an MPN is not validly constituted may petition the administrative director to suspend or revoke approval of it. 
    • A. 

      True

    • B. 

      False

  • 31. 
    Administrative penalties established by the administrative director per violation cannot exceed. 
    • A. 

      $1000

    • B. 

      $3000

    • C. 

      $5000

  • 32. 
    Labor Code (LC) section 4616(b)(5) provides that the administrative directors determination may be reviewed on by an appeal filed as an original proceeding before the Reconsideration Unit of the appeals board. 
    • A. 

      True

    • B. 

      False

  • 33. 
    LC 4616.3(b) applies to any case still pending, subject only to the appeals board continuing jurisdiction.
    • A. 

      True

    • B. 

      False

  • 34. 
    The employers failure to provide notice as required or failure to post notice, shall not be a basis for the employee to treat outside the MPN unless it is shown that the failure to provide notice resulted in a denial of medical care.
    • A. 

      True

    • B. 

      False

  • 35. 
    The appeals board holds that an employee has the burden to prove a denial of medical care under LC 4616.3(b), and that the applicant did not carry this burden.
    • A. 

      True

    • B. 

      False

  • 36. 
    If an applicant has pre-designated a physician prior to any injury occurring, he or she is not subject to treatment within the MPN.
    • A. 

      True

    • B. 

      False

  • 37. 
    After an employee's first visit to the MPN, the employer is required to notify the employee of his or her right to be treated by any physician within the network.
    • A. 

      True

    • B. 

      False

  • 38. 
    CCR9767.5(d) provides that the employee may change MPN physicians at any point after the initial evaluation.
    • A. 

      True

    • B. 

      False

  • 39. 
    If an applicant is dissatisfied with a MPN physician and wishes to change physicians within the network, failure to notify him or her about how to do so is not considered a denial of medical treatment.
    • A. 

      True

    • B. 

      False

  • 40. 
    Per Labor Code (LC) 4603.2(a)(2), if the employee objects to the employee's selection of the physician on the grounds that the physician is not within the medical provider network used by the employer, and there is a final determination that the employee was entitled to select the physician, the employee shall be entitled to continue treatment with that physician at the employer's expense.
    • A. 

      True

    • B. 

      False

  • 41. 
    • A. 

      Inadequate notice from the employer of MPN

    • B. 

      Pre-designation prior to an injury

    • C. 

      MPN physician not reasonably geographically located to the applicants residence

    • D. 

      All of the above

  • 42. 
    Per Labor Code (LC) 4603.2(a)(3), if an employer objects to the employee's selection of the physician on the grounds that the physician is not within the medical provider network used by the employer, and there us a final determination that the employee was not entitled to select a physician outside of the medical provider network, the employer shall have no liability for treatment provided by or at the direction of that physician or for any consequences of the treatment obtained outside the network.
    • A. 

      True

    • B. 

      False

  • 43. 
    Every employer or insurer has been requested to establish a medical treatment authorization review process.
    • A. 

      True

    • B. 

      False

  • 44. 
    In what year every employer or insurer was required to establish an Utiltization Review Process?
    • A. 

      1994

    • B. 

      2000

    • C. 

      2004

  • 45. 
    Under which Labor Code (LC) if an applicant disputed a utilization review decision to delay, deny, or modify a request for authorization or medical treatment?
    • A. 

      LC 4060

    • B. 

      LC 4062

    • C. 

      LC 4062(a)

  • 46. 
    An applicant is required to notify the employer of the objection within how many days of an objection to a UR denial?
    • A. 

      15 days

    • B. 

      20 days

    • C. 

      30 days

  • 47. 
    Under SB 863, the Legislature made changes to the UR process and established the independent medical review (IMR) process.
    • A. 

      True

    • B. 

      False

  • 48. 
    IMR process applies to all injuries occurring on or after January 1, 2013.
    • A. 

      True

    • B. 

      False

  • 49. 
    SB 863, requires that final determination made pursuant to the independent medical review process be presumed to be correct. 
    • A. 

      True

    • B. 

      False

  • 50. 
    IMR was designed to eliminate litigation over medical treatment disputes, and give the parties limited options for appealing an independent medical reviewer's decision.
    • A. 

      True

    • B. 

      False

  • 51. 
    Per Labor Code 4610(g)(7), utilization review of a treatment recommendation shall not be required while the employer is disputing liability for injury or treatment of the condition for which treatment is recommended.
    • A. 

      True

    • B. 

      False

  • 52. 
    If a defendant defers UR because it is disputing liability for the injury or on the grounds other than medical necessity, it must give notice of its intent to do so. 
    • A. 

      True

    • B. 

      False

  • 53. 
    A defendant defers UR because it is disputing liability for the injury or on grounds other than medical necessity, it must give notice of its intent.  A written decision deferring UR must be provided within how many days?
    • A. 

      3

    • B. 

      5

    • C. 

      10

  • 54. 
    The time limit to conduct retrospective UR begins on the date the determination to liability becomes final.
    • A. 

      True

    • B. 

      False

  • 55. 
    • A. 

      Applicant

    • B. 

      Physician requesting the authorization

    • C. 

      Attorney representing the applicant

    • D. 

      All of the above

  • 56. 
    A retrospective UR is required when "the employer's liability becomes final"
    • A. 

      True

    • B. 

      False

  • 57. 
    A Prospective UR is required after "the determination of the employer's liability."
    • A. 

      True

    • B. 

      False

  • 58. 
    Retroactive UR begins on the date the determination of liability becomes final.
    • A. 

      True

    • B. 

      False

  • 59. 
    For the purposes of retrospective UR, the employer has how many days to conduct a retrospective UR?
    • A. 

      5 days

    • B. 

      10 days

    • C. 

      20 days

    • D. 

      30 days

  • 60. 
    LC 4610(g)(8) says the time for prospective UR "shall commence from the date if the employer's receipt of a treatment recommendation after the determination of the employer's liability.
    • A. 

      True

    • B. 

      False

  • 61. 
    For injuries on or after January 2, 2013, and for all injuries if the employer's decision on the request for treatment is communicated on or after July 1, 2013, treating physicians generally must request authorization for medical treatment on a specific form.
    • A. 

      True

    • B. 

      False

  • 62. 
    Per CCR 9792.6.1(t), requests for medical treatment are to be made on form DWC RFA (request for authorization).
    • A. 

      True

    • B. 

      False

  • 63. 
    The request for authorization (RFA) must be completed by the primary treating physician.
    • A. 

      True

    • B. 

      False

  • 64. 
    A request for authorization (RFA) completed by a secondary treating physician could trigger the utilization review process.
    • A. 

      True

    • B. 

      False

  • 65. 
    Requests for authorization for medical treatment that does not utilize the RFA must have the following written on the request.
    • A. 

      Request for authorization clearly written on the top of the page of the document.

    • B. 

      List all requested medical services, goods, or items on the first page.

    • C. 

      Be accompanied by documentation substantiating the medical necessity for the request.

    • D. 

      All of the above

  • 66. 
    Parties seeking to strike a Qualified Medical Examiner (QME) must do so within how many days of assignment by the Administrative Director (AD)?
    • A. 

      5 days

    • B. 

      7 days

    • C. 

      10 days

  • 67. 
    Parties may agree to an Agreed Medical Examiner (AME) anytime.
    • A. 

      True

    • B. 

      False

  • 68. 
    An employee who has selected a Qualified Medical Examiner has how many days to schedule an appointment?  
    • A. 

      5

    • B. 

      7

    • C. 

      10

  • 69. 
    Within how many days a Qualified Medical Examiner must schedule an examination of the initial request for an appointment?
    • A. 

      20

    • B. 

      30

    • C. 

      60

  • 70. 
    The party with the legal right to schedule an appointment may choose to accept one no more than 60 days from the initial request.
    • A. 

      True

    • B. 

      False

  • 71. 
    An unrepresented employee has the first opportunity to request a Panel Qualified Medical Examiner (QME).
    • A. 

      True

    • B. 

      False

  • 72. 
    A panel must be assigned within 10 working days, or the employee may select a Qualified Medical Examiner (QME) of his/her choice within a reasonable geographic area.
    • A. 

      True

    • B. 

      False

  • 73. 
    Only the employee can request a report for factual correction within 30-days of its receipt.
    • A. 

      True

    • B. 

      False

  • 74. 
    The Qualified Medical Evaluator must issue a factual correction within how many days?
    • A. 

      10

    • B. 

      15

    • C. 

      30

  • 75. 
    If a party provides information to an AME/QME, it must be served on the opposing party within how many days?
    • A. 

      15

    • B. 

      20

    • C. 

      30

  • 76. 
    If the opposing party objects to consideration of nonmedical records with 10 days, they must not provided to the evaluator unless ordered by a Workers' Compensation Judge (WCJ). 
    • A. 

      True

    • B. 

      False

  • 77. 
    An initial medical evaluation must be prepared no more than how many days?
    • A. 

      10

    • B. 

      20

    • C. 

      30

    • D. 

      45

  • 78. 
    An extension of how many additional days can a evaluator be given to complete a report? 
    • A. 

      20

    • B. 

      30

    • C. 

      60

  • 79. 
    A supplemental report must be completed within how many days from the date of the request?
    • A. 

      30

    • B. 

      45

    • C. 

      60

  • 80. 
    Evaluators must be available for deposition within 120 days of the notice of deposition unless the appeals board orders otherwise or the parties agree otherwise.
    • A. 

      True

    • B. 

      False

  • 81. 
    The QME fees shall be prima facie evidence.
    • A. 

      True

    • B. 

      False

  • 82. 
    Reports by treating or consulting physicians, other than comprehensive, follow-up or supplemental medical legal evaluations, regardless of whether liability for the injury has been accepted at the time the time the treatment was provided or the report was prepared, shall be subject to the official medical fee schedule.
    • A. 

      True

    • B. 

      False

  • 83. 
    The fee for each evaluation is calculated by multiplying the relative value by $10.50, and adding any amount applicable because of the modifiers permitted.
    • A. 

      True

    • B. 

      False

  • 84. 
    Fees for each medical-legal evaluation procedure includes reimbursement for the history and physical examination, review of records, preparation of a medical-legal report, including typing and transcription services, and overhead expenses.
    • A. 

      True

    • B. 

      False

  • 85. 
    Under section 17 of Title 8 of the California Code of Regulations all physicians shall pay the required QME fees yearly intervals within 30 days of receipt from the Administrative Director that the QME fee for the next 12 months is due and payable.
    • A. 

      True

    • B. 

      False

  • 86. 
    A QME who fails to pay the required statutory fee within 30 days of receipt of a final notice shall be terminated from the official QME roster. 
    • A. 

      True

    • B. 

      False

  • 87. 
    If the QME fee is not paid within two years from the due date in the final fee notice from the AD, then the physician shall submit a new application, pass the competency examination and pay they appropriate fee before regaining or obtaining QME active status.
    • A. 

      True

    • B. 

      False

  • 88. 
    ML101 represents a follow-up medical-legal evaluation.
    • A. 

      True

    • B. 

      False

  • 89. 
    ML100 represents missed appointment for a comprehensive or follow-up medical-legal evaluation.
    • A. 

      True

    • B. 

      False

  • 90. 
    A ML102 is a complex comprehensive medical-legal evaluation.
    • A. 

      True

    • B. 

      False

  • 91. 
    The IBR process turns the decision-making process over to medical billing and payment experts.
    • A. 

      True

    • B. 

      False

  • 92. 
    • A. 

      True

    • B. 

      False

  • 93. 
    IBR went into effect for all dates of service on or after January 1, 2013.
    • A. 

      True

    • B. 

      False

  • 94. 
    If a physician disagrees with the amount of payment made by a claims administrator on a bill, the physician may request the claims administrator to conduct a second review of the bill.
    • A. 

      True

    • B. 

      False

  • 95. 
    The second bill review is required to initiate IBR and must be requested within 60 days.
    • A. 

      True

    • B. 

      False

  • 96. 
    • A. 

      $100

    • B. 

      $125

    • C. 

      $150

  • 97. 
    • A. 

      Healthcare Service Plans

    • B. 

      Group Disability Insurers

    • C. 

      Self-Insured Employee Welfare Benefit Fund

    • D. 

      All of the Above

  • 98. 
    The Taft-Harley health and welfare funds and publicly funded programs providing non-industrial medical care is not one of the exemption.
    • A. 

      True

    • B. 

      False

  • 99. 
    Lien payments can only be made by cash or check.  No electronic payments are accepted.
    • A. 

      True

    • B. 

      False

  • 100. 
    For services provided prior to July 1, 2013, the lien must be filed within three years of the date of service was provided.  For services provided on or after July 1, 2013, the time frame is reduced to 18 months.
    • A. 

      True

    • B. 

      False