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A Brief Discussion About the Qualified Medical Evaluator (QME) Process

The Law Offices of Jonathan M. Brand May 4, 2018

If you have suffered a workplace-related illness or injury, and have submitted a claim under your employer's workers' compensation insurance policy, you may decide or be required to see a Qualified Medical Evaluator ("QME"). A QME, is a physician who is specially qualified to provide medical-legal evaluations of a worker's job-related injuries. In this article, we explain what the purpose of a QME is, some details of the process, along with the pros and cons of requesting a QME and how that may affect your particular circumstances.

The purpose of a QME is to evaluate your workplace-related injury or illness when there is a question about what workers' compensation benefits you should receive. The basic idea is that a QME can provide a neutral evaluation of your condition, and help resolve any dispute or disagreement between you and the workers' compensation insurance carrier over whether, or how much, or for what conditions, you should receive benefits. QMEs are trained to evaluate a number of different injury situations. Some of the more difficult injuries to evaluate are injuries to the psyche. When a person is emotionally traumatized by an event such as sexual harassment, workplace violence, a workplace robbery, etc., the necessary compensation can be difficult to determine. A QME is a physician or other health care professional who meets certain qualifications set by the California Division of Workers Compensation ("DWC") Medical Unit.

Who Decides If You Need to See a QME?

Either you or the workers' compensation insurance claims administrator can request that you see a QME. But, you get the first crack. Here's how it works. If there are questions about your workers' compensation claim that a QME might be able to help sort out, you can fill out a QME request form obtained from the DWC Medical Unit website above. Alternatively, you may receive a QME request form directly from the workers' compensation carrier, in which case you have ten days from receiving the form to request a QME. It's up to you if you want to make the request. If you don't make the request within the ten-day window, however, then your time is up and the workers' compensation insurer gets the chance to request a QME.

Who Picks the QME?

Whoever fills out the QME request form decides the specialty of the QME you will see. As a practical matter, the specialty you or the claims administrator chooses for the QME ought to have something to do with your injury or illness, or with the reasons why there are questions about your claim. For example, if you suffered a twisting knee injury and there's a question about how severe the injury was, you could request that the QME be an orthopedist.

It's important to understand, however, that you don't get to name your QME directly. Instead, if a QME is requested by either party, the DWC Medical Unit will send you a randomly generated list (or "panel") of three approved QMEs in the requested specialty to choose from. You have ten days from when the list is generated to select one of the doctors on the QME list, tell the insurance company who you picked, and make an appointment. If you miss that deadline, the workers' compensation insurance carrier has the right to select the QME you will see and make the appointment for you. If you are entering this process without qualified legal counsel, you may end up choosing a QME who will assess your injury in a way that offers you less compensation than you deserve.

Who Pays for a QME?

In California, the workers' compensation insurance company pays for the QME exam, regardless of who requested it.

What Happens at a QME Examination?

A QME examination is basically a doctor's appointment at which the doctor evaluates your workplace-related injury or illness, with an eye to helping resolve the dispute or question that led to the QME being appointed.

What Are the Pros and Cons of Requesting a QME?

A QME can be a convenient way to resolve a dispute or question about your eligibility for workers' compensation benefits. For example, if you disagree with your regular doctor's assessment of your injury or illness and how it affects whether you are entitled to benefits, a QME can offer a second, more useful opinion for resolving your claim.

But, beware, requesting a QME (or having one requested by the workers' compensation insurance carrier) can carry significant risks. You may not be satisfied with the QME options presented to you in your "panel." The specialty of the QME may affect how your injury or illness is perceived and judged, and may not be appropriate for establishing you are entitled to benefits. A qualified Workers’ Comp Attorney will help you choose an excellent doctor from a QME panel and fight for the payout you deserve.

How Does an Attorney Help With the QME Process?

Consulting with an attorney may help you avoid some common, but serious, risks and mistakes in the workers' compensation and QME process. If you have an attorney, your attorney and the claims administrator may agree on a doctor without going through the state system used to pick a QME. The doctor your attorney and the claims administrator agree on is called an agreed medical evaluator (AME). as an alternative to being forced to select a QME from a randomly generated list.

Contact an experienced workers' comp attorney from Brand Peters PC for assistance in choosing a QME who will get you the compensation you deserve. ​​​​​ Call the firm today to receive your free initial consultation.