So you are hurt at work and soon thereafter a packet of papers from the insurance adjuster arrives in the mail. It's a bunch of paperwork that you don't understand including information about obtaining a Qualified Medical Evaluation (QME). You could call the adjuster and ask about it. But then you remember that the adjuster works for the insurance company and isn't interested in guiding you to more benefits. Instead, they are likely to provide advice that will limit you going further with the claim. That's why we put together this very blog article on the topic. This isn't a comprehensive legal guide. It is the ultimate qualified medical evaluation Frequently Asked Questions (FAQ) for injured workers who need information.
What is a Qualified Medical Evaluator?
A QME is a physician who is appointed by the Division of Workers' Compensation (DWC) to perform an evaluation to determine the extent of your industrial injury, and whether or not you have permanent disability. A QME must be impartial – they cannot have any financial interest in your case. Keep in mind that insurance company pays for this doctor to perform the evaluation. While impartiality is expected, it isn't always provided by the doctor your insurance company selects as your QME.
Can I Select My Own Qualified Medical Evaluator As An Injured Worker?
Yes, you can pick your own doctor as a QME if you act within certain time limits and follow the proper procedures. The Department of Workers' Compensation (DWC) website has a list of doctors who are currently taking injured worker patients for QMEs. These are known as panels. When you request a panel of doctors from the DWC, the Medical Unit sends you a list of three to choose from.
As an unrepresented worker, you have the choice so long as you act within the proper time limits. You are at your adjuster's mercy if you fail to request a QME or you don't inform the adjuster of your selection once the list arrives.
You have the right to choose your own QME, but there are a few things you need to keep in mind.
- You must first obtain the list by mailing the appropriate paperwork to the Department of Workers' Compensation Medical Unit.
- You then need to receive the list in the mail. You should have listed your adjuster on the forms so that your adjuster also receives the list.
- You must notify your adjuster of your QME choice within ten days of receiving the list from the DWC. It's best to email your selection and get confirmation of receipt.
- You must schedule the appointment with the QME. If the QME has no available appointments within 90 days, then you may request a new panel of three and start the process over again. Your other option is to choose a different doctor from the list.
How Does An Independent Medical Exam (IME) Differ From QME?
An IME is an examination performed by a physician that has been requested by the insurance company to get their own opinion about your diagnosis, treatment and/or prognosis. The IME doctor is not required to be impartial. In fact, they are often hired by the insurance company because they specialize in finding ways to deny claims. IMEs are generally not used in Workers' Compensation cases in California. These types of examinations are performed in personal injury litigation by the defendant. The IME is the defendant's expert who tries to diminish you case and convince the jury to pay you less money for your medical care, past and future. The IME is usually always conservative and not impartial to the plaintiff.
Do I have to see a QME For My Workers' Compensation Case?
Technically no, but most injured workers with serious injuries should definitely consider getting a QME. If your injury is minor and you are returned to work in short order, then you might not need one. But if you have any type of permanent disability, a disputed body party, disputed medical treatments, or need for job retraining, then it's strongly recommended that you consult with a lawyer about asking for a QME.
If you are asking for a workers' compensation benefit that requires a medical opinion, such as permanent disability or vocational rehabilitation, then you will need to see a QME.
How is A QME different than my Primary Treating Physician (PTP).
Your primary treating physician under workers compensation provides you with treatment. The QME is charged with offering a second opinion. The QME comments on your treatment, disability periods, permanent impairment, need for future medical care, and job retraining. The QME is paid thousands of dollars to generate comprehensive report of their findings. Usually this report is substantial evidence of your injuries and workers' compensation needs. While evidence of your injury from your PTP can be introduced at trial, the QME opinion often holds the most weight to the judge.
What should I do if the adjuster denies my request for a QME?
If the insurance company denies your request for a QME, you need to call the Information & Assistance Officer at your local Workers' Compensation Appeals Board district office. The Insurance company will have to provide a reason why they denied your request and the Judge will decide whether or not to order the insurance company to provide you with a QME.
Should I still get a QME For My Job Accident Claim?
It depends on your specific situation. There are many advantages and disadvantages to having a QME. It is important that you consult with an attorney to discuss whether or not a QME is right for you.
How does the QME process work if I am represented by an attorney?
The process is a little different when you are represented by an attorney. You don't get to select any doctor from the list when you have a lawyer. Instead, your lawyer gets to strike one doctor and the insurance company gets to strike one. Whoever is left is the QME selected for your case. So, while having a lawyer can be helpful, it actually can hurt your chances of obtaining an impartial QME.
Your lawyer will help you through the process. The main difference is that your attorney will likely be more involved in helping you select the right QME and preparing you for your examination. A lawyer makes sure that all your medical records and summaries get to the QME. If the QME report is flawed in some material way, your lawyer can question it.
How do I prepare for my QME examination?
Preparing for QME examination is important. Here are some tips to make yours more successful. Remember that this is not legal advice. This is general information that is mean to help you but it is not legal advice. For legal advice, call a lawyer!
- Be on time or early. It is important to make a good impression.
- Dress neatly and conservatively. You want the doctor to focus on your medical condition, not your clothing.
- Make sure you bring all your medication bottles with you. The QME will want to know what medications you are currently taking.
- Be honest. It is important to be truthful with the QME about your symptoms, pain levels, and how your injury has impacted your life. The QME will use this information to write a report that will be used to make decisions about your case.
What should I expect during the QME examination?
The QME will review your medical records and ask you questions about your injury, symptoms, and pain. The QME will also perform a physical examination. This may include range of motion tests and neurological tests. Be sure to tell the doctor if you are in pain during the examination.
After the examination, the QME will write a report. This report will be sent to the insurance company, your employer, and your attorney (if you have one). The report will include the QME's opinion on your injury, whether or not you are permanent and stationary, your level of disability, and whether or not you need future medical care.
What if I don't like the QME report?
If you don't like the QME report, you can request a copy of your records from the QME. You can also request that the QME clarify anything in the report that you don't understand. If you still disagree with the report, you can ask for a supplemental report or a panel QME.
What is A Final QME Report?
A final QME report is a report that is issued by the QME after they have reviewed all the medical records and evidence in your case. The report will include the QME's opinion on your injury, whether or not you are permanent and stationary, your level of disability, and whether or not you need future medical care.
What is a supplemental QME report?
A supplemental QME report is a report that is issued by the QME after they have reviewed additional evidence in your case. This could be new medical records, updated records, or other information. The supplemental report will include the QME's opinion on your injury, whether or not you are permanent and stationary, your level of disability, and whether or not you need future medical care.
Sometimes the QME will change their mind on causation, body parts involved, permanent impairment level. But this is rare because to do so there must be some new facts that were not addressed in the initial or final report.
What if I don't want to see a QME?
You can refuse to see a QME, but that may limit your ability to get the benefits you are entitled to. If you refuse to see a QME, the insurance company may stop paying your benefits. In some cases, the Judge may order you to see a QME anyway.
What if I can't afford to pay for a QME?
If you can't afford to pay for a QME, you don't need to worry. The insurance company has to pay for the QME and diagnostic testing involved to complete the QME report.
What if I don't have transportation to get to the QME?
If you don't have transportation to get to the QME, you can ask the insurance company to provide you with transportation. The insurance company is required to provide you with reasonable transportation to and from the QME examination.
What if I need special accommodations for my QME?
If you need special accommodations for your QME, you can request them from the insurance company. Examples of special accommodations include having the examination in a location that is handicap accessible, having the examination in a location that is close to public transportation, or having the examination scheduled at a time that is convenient for you.
The insurance company is required to provide you with reasonable accommodations. If the insurance company refuses to provide you with reasonable accommodations, you can ask your attorney for help.
What if the evaluator doesn't show up for my examination?
If the QME doesn't show up for your examination, you can reschedule your examination. You can also ask the insurance company to provide you with a new QME.
What Is the Difference Between a QME and an AME?
A QME is a Qualified Medical Evaluator and an AME is an Agreed Medical Evaluator. The major difference between the two is that a QME is appointed by the workers' compensation board while an AME is mutually agreed upon by both the injured worker and the employer/insurance company. Also, you can only have an AME where you are represented by a lawyer office on your claim.
A QME has the authority to render a decision that is not binding and is only meant to serve as a basis for discussion and negotiation between the two parties . An AME's opinion is binding on both the injured worker and the employer/insurance company.
What if I have more questions?
If you have more questions, you can speak to an attorney. You can also visit the California Division of Workers' Compensation website for more information: http://www.dwc.ca.gov/
Who Is the Ultimate Workers' Compensation Lawyer in California?
The answer to this question depends on many factors. Some workers' compensation lawyers specialize in specific types of cases, such as occupational diseases or injuries, while others may focus on a specific geographical area. Ultimately, the best workers' compensation lawyer for you is one who has the experience and knowledge to successfully handle your case.
When choosing a workers' compensation lawyer, it is important to ask about their experience and knowledge in handling cases like yours. You should also ask about their success rate in obtaining benefits for their clients.
A workers' compensation lawyer should be able to answer all of your questions and help you understand your rights under the workers' compensation system. If you have any doubts about a particular lawyer, you should speak to another one before making a decision.
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