Report 2019-102 Recommendation 6 Responses

Report 2019-102: Department of Industrial Relations: Its Failure to Adequately Administer the Qualified Medical Evaluator Process May Delay Injured Workers' Access to Benefits (Release Date: November 2019)

Recommendation #6 To: Industrial Relations, Department of

To ensure that DWC monitors and reviews QME report quality and timeliness and to ensure the efficient resolution of workers' compensation claims, DWC should, by April 2020, create and implement a plan to continuously review the quality and timeliness of QME reports, including time frames for review, methodology for selecting reports to review, and the minimum number of reports to be reviewed annually.

1-Year Agency Response

DWC created and implemented a plan for reviewing continuously the quality and timeliness of QME reports, as described in Recommendation # 6 and discussed below. (See Exh. M and previously provided Exh. D.)

The DWC developed a process to track the timeliness of QME reports and dedicated staff has been assigned to this endeavor.

The DWC has convened committees of judges, lawyers, physicians, and retired judges to review and comment on the quality of medical-legal reports. The established policy calls for the committees to meet four times a year (i.e., March, June, September, and November). The committee members may attend the quarterly meetings either by phone or in person.

The first committees have already been convened. The committees have received reports for review and joint meetings took place in November 2020. There are currently six committees made up of QMEs, workers' compensation judges, applicant's lawyers, and defense lawyers.

The committee members will review the reports and fill out the quality assessment checklist prior to the individual meetings. Their findings will be discussed at the scheduled meetings and an overall assessment of report quality will be formulated in conjunction with representatives from the QME Discipline Unit Legal Unit attorneys will tabulate the results of all of the committee meetings and formulate a memorandum detailing the committees' findings that will be delivered to the Executive Medical Director.

Please see the full response submitted to the State Auditor on November 18, 2024 for complete details.

California State Auditor's Assessment of 1-Year Status: Fully Implemented

DWC provided an internal process for reviewing the quality and timeliness of medical-legal reports, including time frames for review, a methodology for selection report to review, and the minimum number of reports to be reviewed annually. To the extent that DWC follows through with performing these reviews, it will implement our recommendation.

6-Month Agency Response

DWC 180-Day Status on the Recommendation: Completed.

Timeliness of Reports:

The DWC has a system in place to track timeliness of reports and dedicated staff has been assigned to this project (Frankie Yan and Ruth Manzo, with back-up support provided by Michael Barron). See Exhibit D.

Quality Review of Medical-Legal Reports:

The DWC will convene a committee of judges, lawyers, physicians, and retired judges four times a year (i.e., March, June, September and December) to review and comment on medical-legal report quality. The committee members may attend the quarterly meetings either by phone or in person.

There will be at least five groups made up of five committee members in each group. Each member of an individual group will receive the same 10 redacted medical-legal reports to review 30 days prior to the committee meeting. This should allow for a review of at least 200 reports annually.

Each reviewer will receive a quality assessment checklist to help with the review of the medical-legal report. See Exhibit E.

What reports will be reviewed?

DWC is in the process of amending the QME regulations to require that the QMEs provide, at the time of re-appointment, two medical-legal reports with their reappointment application. See Exhibit F. The Department is currently assessing options for rulemaking with regard to this proposed regulation.

The DWC will also access the Electronic Adjudication Management System (EAMS) in January, April, July and October to obtain at least fifty reports that served as the basis for settlements approved by workers' compensation judges. In addition, the DWC will obtain at least twenty-five reports from the Disability Evaluation Unit (DEU) and twenty-five reports from the DWC discipline unit.

It is anticipated that the committee will be able to review approximately 200 reports annually.

California State Auditor's Assessment of 6-Month Status: Partially Implemented

DWC provided a policy related to reviewing the timeliness of QME reports. However, it did not provide a finalized plan to continuously review the quality of QME reports, which should include time frames for review, methodology for selecting reports to review, and the minimum number of reports to be reviewed annually. Further, it must demonstrate that it has implemented the plan.

60-Day Agency Response

The DWC has a procedure in place to address untimely reporting by QMEs. In consideration of the audit findings, the DWC is assessing this procedure for efficiency. The DWC has held stakeholder meetings to obtain input regarding report quality. The DWC anticipates making regulatory changes regarding obtaining a random sample of reports by requiring QMEs to provide reports at the time of reappointment. The DWC has limited resources to review these reports so the DWC is working with stakeholders to create a committee that can review these reports and provide feedback. The DWC is also working with stakeholders on a standard identifying what constitutes a "quality QME report". Items of agreement from the stakeholder meetings for assessing report quality include complying with the requirements of California Code of Regulations, title 8, section 10606, ensuring that there is no bias in QME reporting, and requiring evidence-based opinions in QME reporting.

The DWC has obtained a consensus from our stakeholder meetings that there should be an increase in the continuing educational requirements for QMEs. The proposal from these meetings indicate that the continuing educational requirements for QMEs should increase from 12 hours a year to 16 hours a year. The proposed specific requirements for education will include 4 hours on impairment rating, 3 hours on report writing, 1 hour on anti-bias, 2 hours on case law, 1 hour on fee schedule or clerical issues, and 1 hour on report review. Based on the results of the annual audit of report quality, the DWC will provide recommended topics for QME educational courses to improve quality. The DWC is in the process of drafting regulations to implement this change.

California State Auditor's Assessment of 60-Day Status: Pending

All Recommendations in 2019-102

Agency responses received are posted verbatim.