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What is the Importance of a QMEs in a Workers Compensation Case

A computer randomly assigns qualified medical examiners (QMEs) to workers’ compensation cases in California. The importance of QMEs in a workers’ compensation case cannot be overstated. In many cases, the QME or a QME panel plays a key role in ensuring an injured worker gets the care they need. This is especially true in situations when the worker has lasting injuries and will receive ongoing payments or negotiate a lump-sum settlement.

If you were hurt at work and experience any issues with your workers’ compensation case, a workers’ compensation lawyer can help. With an attorney on your side, you can even choose the doctor you use as your QME.

Understanding What a QME Is and Their Role in Workers’ Compensation Cases

importance of QMEs in a workers’ compensation case

A QME is a physician certified by the State of California to evaluate injuries and illnesses as a part of workers’ compensation claims. The QME conducts examinations for the purposes of:

  • Determining the best course of treatment
  • Considering the prognosis
  • Assigning a disability rating

Injured workers with serious health concerns, lasting impairments, or disputed injuries may need to see a qualified medical examiner in addition to their treating physician, specialists, therapists, and other healthcare professionals.

As noted, computers assign QMEs randomly in California. The injured worker receives the notification of the assigned QME and must make an appointment for an in-depth examination. The QME will determine the necessary tests and later create a report that outlines their:

  • Diagnosis
  • Necessary treatment plan
  • Working ability
  • Everyday life
  • Prognosis

QMEs must meet rigorous requirements. According to the California Division of Workers’ Compensation (DWC), this includes education and licensing rules, as well as passing a special test and meeting continuing education goals.

When Does an Injured Worker Need a QME?

There are several scenarios when an injured worker needs to undergo a QME examination. This could include:

Disputes About the Cause or Condition

Many workers’ compensation claimants see QMEs when the insurance company or their employer disputes their condition’s cause. These parties may not believe the condition is work-related or as serious as the injured person claims.

In these cases, the QME report can affect the worker’s ability to get benefits. This allows the injured person to take time off work as necessary. Yet, if the QME agrees with the insurer or employer’s allegations, the claimant could miss out on medical care, wage benefits, and more.

Disputes About Necessary Treatment

If you and your doctor disagree about how to treat your condition, you can challenge them using a QME exam and their resulting report. This may be easier than getting the insurance company to pay for a second opinion.

Your employer or the insurer can request a QME examination, too. This commonly occurs when they do not believe a worker requires the treatment prescribed or that there are less expensive options available.

When You Have Lasting Injuries

Anytime a workplace injury leads to lasting impairments, a QME exam is likely. These examinations and reports play a central role in establishing the worker’s disability rating for long-term wage loss coverage through workers’ compensation.

Since the report is essential to determining eligibility for disability income through the workers’ compensation insurer, you will want to attend a QME exam before officially resolving your case.

Can I Choose My Own QME?

Generally, every injured worker who needs a QME exam receives a randomly assigned examiner through the state’s computer system. However, there is an exception to this rule. You can choose your own doctor to serve as this examiner when you hire a Los Angeles workers compensation lawyer to handle your workers’ compensation case, and they can convince the insurer to agree.

When you have an attorney working on your case, they can work with the insurer to use another physician besides the assigned QME for this comprehensive examination. This party is known as an agreed medical evaluator (AME). An AME may or may not meet the qualifications of a QME.

Often, the AME is someone already familiar with the case. They could be the treating physician if the claims administrator agrees with that decision. Your attorney can help you understand how this works and identify the options for an AME in your case.

Is Seeing a QME Necessary in My Workers’ Compensation Case?

When the injured worker and the claims administrator both agree with the report from the treating physician, a QME examination is usually unnecessary. This is the easiest possible outcome in these cases and frequently occurs with relatively minor injuries. It can also happen with serious injuries, including those with lasting disabilities.

Under Labor Code sections 4061(d), the report on a workers’ compensation injury must contain certain information that allows the Disability Evaluation Unit to rate the worker’s disability based on their diagnosis, limitations, and prognosis. So long as the doctor’s report meets this criteria and everyone involved agrees with it, a QME is not necessary.

When an injured worker can skip the QME assessment, this saves time and stress. They do not have to attend another comprehensive evaluation, undergo additional testing, or wait for the report to come back. Instead, they can move forward with their claim and seek just compensation without the wait.

Do I Need a QME for a Personal Injury Case?

QMEs in a workers’ compensation case

The short answer: no. Workers’ compensation is a no-fault system, meaning you can pursue benefits even if you caused the incident. However, some workplace accidents result from negligence. For instance, you may have slipped and fallen while stocking items at a grocery store. Another party may have caused a collision while you operated a company-owned vehicle.

In either of those situations, if you can prove that another party’s actions caused your injuries, you could hold them liable through a personal injury claim or lawsuit. In these instances, while seeking medical care is necessary, visiting with a QME is not. QMEs are exclusive to workers’ compensation cases.

Discuss Your Workers’ Compensation Case With Our Team for Free

At KJT Law Group, our team offers free consultations for victims of workplace injuries in California. We can review your case and discuss your options. We can handle your claim, appeal, or lawsuit. Our Los Angeles personal injury lawyers are not afraid to fight for the workers’ compensation benefits you deserve. Contact us by calling (818) 507-8525.

We Will Fight For You

Contact our firm to get started.
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