Qualified medical evaluators (QME’s) or agreed medical evaluators (AME’s) examine injured workers to determine the benefits they will receive if there is a disagreement over the treating physician’s opinions.
QME’s are physicians licensed to practice in California as medical doctors, osteopaths, chiropractors, psychologists, dentists, optometrists, podiatrists or acupuncturists and are certified by the Division of Workers’ Compensation Medical Unit to perform medical/legal evaluations.
AME’s are physicians selected by agreement between the defense and applicant’s attorneys to perform medical/legal evaluations in a workers’ compensation case. AME’s are only used if the injured worker is represented by an attorney.
What’s the difference between a QME and an AME?
If you have an attorney, your attorney and the claims administrator may agree on a doctor without using the state system for getting a QME. The doctor they agree on is called an AME. If they cannot agree, they must ask for a QME.
I’ve been to the doctor. Why do I need to see a QME?
You and/or the claims administrator might disagree with what the treating doctor says. There could also be other disagreements over medical issues in your claim. A different doctor — an AME or QME — has to address these disagreements, which might include:
• Whether or not your injury was caused by your work
• Whether or not you need treatment for your injury (only if date of injury is before Jan. 1, 2013)
• Whether or not you need to stay home from work to recover
• Whether your condition is permanent and stationary
• Whether you have new and further disability
• A permanent disability rating
Who makes the decision about going to a QME?
You, your attorney or the claims administrator can request a QME exam.
The DWC Medical Unit will provide whomever makes the request with a list (called a panel) of three QME’s. Each QME panel is randomly generated and the physicians listed are specialists of the type requested. One physician from the list is chosen to examine you and make a report on your condition. Once a QME is chosen for your claim, most disputes must go to that QME.
How do I request a QME exam?
Complete the “Request for QME panel” form and submit it to the DWC Medical Unit. See Information & Assistance (I&A) guide 2 for help with this form.
NOTE: If your employer or claims administrator says there’s a problem with your claim and sends you a “Request for QME panel” form, you have 10 days to complete the form, select the QME medical specialty and send the form to the DWC Medical Unit. If you do not submit the form within 10 days, the claims administrator will do it and will get to choose the kind of doctor you’ll see.
What difference does it make who submits the form to request the QME?
Whoever submits the request form picks the specialty of the doctor for the exam. See I&A guide 2 for more information. When you receive the panel, you will also receive a letter that explains how to set up the QME appointment and how to provide the QME with important information about yourself. Within 10 days of the date on the list, you must pick a QME from the list, make an appointment and tell the claims administrator. If you do not do this, the claims administrator may select the doctor and make the appointment for you.
Is there anything I can do if I disagree with what the QME says?
Yes, you have 30 days from the receipt of the report to decide if you agree with the QME’s report or if you need more information. When you receive the report, read it right away and decide if you think it is accurate. If not, and you have an attorney, you should talk to him or her about your options.
If you don’t have an attorney, first call the claims administrator. If that doesn’t help, contact an I&A officer at your local Workers’ Compensation Appeals Board (WCAB) district office. The I&A officer can help you figure out what’s best in your case.
If you are in a union, you may be able to see an ombudsperson or mediator under the terms of your collective bargaining agreement or labor-management agreement.
I’m in a medical provider network (MPN). Does the QME process apply to me?
Yes, the QME process may still be utilized if you are part of a MPN.
I still have questions. Who do I contact?
If you have questions about requesting a QME panel, contact the DWC Medical Unit by phone at (800) 794-6900 or by writing to: DWC Medical Unit, P.O. Box 71010, Oakland, CA 94612