What is a QME?
If you are injured while on the job, you may be eligible for workers’ compensation. In order to bring a claim for workers’ compensation in California, there are a variety of legal hoops and hurdles you must overcome. If you and your employer or the insurer have any disagreements as to what benefits you qualify for as a result of your accident, then you may have to see a qualified medical evaluator (QME) in order to have the dispute resolved. Read on for an explanation of QMEs and their purpose, and contact a seasoned Southern California workers’ compensation attorney if you need help with a workers’ compensation claim on behalf of yourself or a deceased family member.
What do QMEs do?
A qualified medical evaluator is a physician who is certified by the Division of Workers’ Compensation (DWC) as a specialist in some particular field of expertise. QMEs receive special training in order to examine injured workers and provide an unbiased view on medical issues that are in dispute as part of a workers’ compensation matter.
QME’s are identified on a specific list maintained by the state of California. After your injury and at the request of the insurance claims adjuster, the DWC will send you a list of three qualified medical evaluators based on the specialty you select and your location. You then have 10 days to select a QME, make an appointment, and notify your employer. If you do not meet the deadline, the DWC will choose a QME for you.
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A workers’ compensation adjuster may request that you see a QME if there is a question as to an element of your injury such as the extent of your injuries, the extent of any resulting disability, or the likely cost of treatment. If your treating physician gives you a permanent disability rating, it is likely the insurance company will want your disability verified by a QME.
The QME will evaluate you and issue an expert opinion either agreeing or disagreeing with your treating physician and resolving any other outstanding dispute over medical issues relating to your workers’ compensation claim. QMEs can include medical doctors, dentist, psychologists, or any other qualified medical professional.
Some QMEs are known to be more friendly towards employers or towards employees. Your workers’ compensation attorney can help you pick the best QME from your options or, as discussed below, find an AME.
WHY DO I NEED A QME DOCTOR?
You need to visit a QME doctor for evaluation and to determine your work-related injuries actually happened as indicated in your claim statement. Since QMEs ought to give an unbiased report, a workers’ compensation adjuster will request a QME exam to create an expert medical report highlighting your illness or injury.
QMEs are supposed to be selected randomly from a list of state-certified doctors. The Division of Workers Compensation usually issues the list. Unfortunately, finding an unbiased qualified medical examiner can sometimes be a considerable challenge since the worker’s comp adjuster would want to work in favor of the company by selecting a QME who is more friendly to the employer. The adjuster may choose some of his doctor friends to perform the exam. Considering this, engaging an experienced Southern California workers’ compensation attorney is your best shot for a fair QME examination process.
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WHAT HAPPENS DURING QME EVALUATION?
During the QME exam, the doctor will examine you to establish the extent of your work-related injuries. The medical examiner will also assess your medical records to rule out any possibility that your current injuries result from an underlying condition or a recurring condition.
The QME evaluationprocess will also look into the severity of your injury and establish whether you have a permanent disability, and decide what treatments you might need.
PREPARING FOR A QUALIFIED MEDICAL EXAMINATION
The outcome of the QME process will determine whether your worker’s compensation claim succeeds or not. With this in mind, it is vital to prepare for the examination way before the scheduled date. Here are some tips on how to prepare for a QME exam.
- Make a physical list highlighting the intensity of your injuries
- Make another list indicating secondary side effects such as headaches, depression, loss of sleep, numbness, anxiety, panic attacks, and visual impairment.
- Write how each part of your body has been affected by the injury or medication
- Rate all areas affected on a scale of 1 to 10
- Produce a detailed timeline of your experience before and after the accident to the date of your QME appointment
HOW LONG DOES A QME REPORT TAKE TO COME OUT?
According to the Division of Workers Compensation, a qualified medical examiner has 30 calendar days to issue a report. The examiner has to provide the report 30 days from the date of commencement of the QME exam
However, the QME may request an extension under the following circumstances:
- If the physician is awaiting the results from requested medical tests
- If the physician consulted a third party healthcare worker and he or she is awaiting the report from the consultant
- A logical reason or reasonable cause like a natural disaster, death in the evaluator’s family, medical emergencies, and other unavoidable circumstances
However, such an extension may not exceed 15 days.
HOW LONG DOES IT TAKE TO SETTLE A QME WORKERS COMPENSATION CASE?
It takes 30 to 60 calendar days to close a qme worker’s comp case. The state board must first approve your QME workers’ compensation before the insurance company begins the process of paying your claim.
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What about an AME?
If you have legal representation, then you may be able to see an agreed medical evaluator (AME) instead of a QME. Typically the state system will be used to pick a QME. If you have a lawyer, then your attorney and the workers’ compensation claims administrator can come to an agreement on which doctor will evaluate you. Once the AME has evaluated you, you are not then able to go see a QME; you are limited to the AME’s report. The AME may be a QME but does not have to be one.
AMEs are chosen by both sides and do not represent the claims adjuster or the employee. All parties–the employer, the employee, and the insurance company– are agreeing to be bound by the AME’s opinion. Your workers’ compensation attorney can help you determine if an AME is your best option and, if so, negotiate with the other parties to pick an appropriate doctor.
Hurt on the Job in Southern California? Call a Board-Certified Workers’ Compensation Specialist
If you have a claim for workers’ compensation and want to make sure you get the maximum available coverage, call Invictus Law today at (888) 996-7552, and speak with an experienced California workers’ compensation attorney to evaluate your claims.