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What Does PQME Stand for in Workers’ Compensation?

PQME stands for “panel qualified medical evaluator.” The term “panel” refers to a short list of medical professionals authorized to perform health status evaluations for workers’ compensation cases. Typically, a qualified medical evaluator (QME) panel administrator or California’s Division of Workers’ Compensation (DWC) selects this panel.

A QME is a licensed physician who must meet specific criteria and receive certification from the DWC to evaluate and provide medical opinions in workers’ compensation cases. QMEs must go through specialized training and pass a certification exam.

What Are PQMEs and QMEs?

In California, PQMEs are chosen from a panel of QMEs. If a worker does not have legal representation and there is a dispute in a workers’ compensation case, the DWC assigns this panel to assess the worker’s medical condition or treatment. This panel includes three medical professionals from different specialties qualified to assess the medical issues involved in the case. According to California’s Department of Industrial Relations (DIR), QMEs include various practitioners, including physicians, osteopathic doctors, chiropractors, podiatrists, therapists, and others.

Each QME panel is randomly generated, and the physicians selected are specialists of the type of medical professional requested. Once a QME is selected for a case, all medical disputes must be directed to that QME. Moreover, because the panels are arbitrary, a worker cannot reject them, even if they feel the selected QMEs will not provide a fair report.

The injured worker, the insurer, or the employer can select a PQME from the panel to conduct the evaluation. The PQME must provide an impartial assessment and a clearer understanding of the worker’s medical condition, type and scope of their injury, need for medical treatment, degree of disability, and other information. The evaluation aims to help resolve disputes and offer guidance for determining suitable benefits and treatment.

Is a PQME Always Needed or Required?

When there is a dispute concerning an injured worker’s medical condition or treatment, involving a PQME is one option to help resolve the disagreement. However, using a PQME for a dispute is not always necessary. Sometimes, informal methods can resolve disputes, such as discussions between the worker, employer, and insurer or via negotiations with a claims adjuster or workers’ compensation lawyer.

If these parties agree without a formal medical assessment, a PQME may not be required. The parties could also opt to engage in mediation or other alternate dispute resolution methods to resolve their disagreements without a formal hearing. If the parties cannot resolve the dispute through these processes, a party to the case can ask for a PQME evaluation.

What Information Is Collected in a PQME Evaluation?

During a PQME evaluation, the information gathered may vary depending on the injury or illness and the evaluation’s purpose. For those with legal representation, the lawyer and the claims administrator may agree on a physician called an agreed medical evaluator (AME). Information compiled from similar medical exams used in workers’ compensation cases indicates many common elements in these evaluations may be included:

  • Interview: The injured worker may be asked to participate in an interview or fill out a questionnaire to gather more information about their experiences regarding the accident, symptoms, pain levels, treatment, physical limitations, and more.
  • Medical History: This includes any prior injuries, illnesses, or pre-existing conditions that may be pertinent to the current workers’ compensation claim. This includes information about previous treatments, surgeries, and medications.
  • Physical Exam: This is conducted by the PQME to assess the worker’s current condition. It may involve evaluating the range of motion, strength, reflexes, sensation, and other relevant physical factors. Objective measurements may be performed for these and other physical characteristics, depending on the nature of the injury or illness.
  • Diagnostic Tests and Reports: This includes a review and analysis of diagnostic tests such as X-rays, MRIs, CT scans, or lab results to collect objective information about the worker’s condition. The PQME may also consider reports from other medical providers involved in the worker’s care, such as primary care providers, specialists, or therapists.
  • Functional Assessment: This may include the injured worker’s functional abilities and limitations related to their work duties. It can help determine the injury or illness’ effect on the worker’s ability to carry out job-related tasks. Additionally, this assessment can identify modifications or accommodations that support the worker’s return to work.
  • Medical Records Review: This would include relevant medical records, such as those from treating physicians, hospitals, or rehab facilities. The purpose is to give the PQME a comprehensive understanding of the worker’s medical treatment, interventions, and progress.

How to Prepare for Your Medical Exam

Preparing for your medical examination can be helpful. Be on time or early, and dress appropriately. Bring any medication you’re taking and know your medical history and course of treatment. Being honest with the QME about your symptoms, pain levels, and how your injury or illness affects your life is important. The physician will use this information to compile a report to help them make decisions about your case.

You can contact a worker’s compensation lawyer if you want legal advice at any point before this exam. If, for some reason, the physician doesn’t show up for your exam, you can reschedule or ask the insurer to provide you with a new QME. The QME cannot offer ongoing medical care because they are not your treating physician. Additionally, any details provided during the examination could be used in court cases involving your workers’ compensation claim.

Contact a Workers’ Compensation Lawyer Today for PQME Guidance

At KJT Law Group, we understand the importance of receiving fair compensation for workplace injuries and illnesses, especially for families that cannot afford to lose income. Our legal professionals can answer your questions and help you navigate California’s complex workers’ compensation process. We can explain what PQME stands for in a benefits claim and how their role could affect your case. Contact us today at (818) 507-8525 for a free consultation.

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