Qualified Medical Examination Panels: Why They Matter in Your Workers’ Compensation Case
In 2023 alone, California’s workers’ compensation system recorded 680,152 initial reports of injury. Many of these workers face staggering medical bills, lost wages, and an uncertain road to recovery. While some of their claims proceed smoothly, others face disputes with insurance companies about the nature of an injury or the necessity of medical care. When these disputes arise, the solution is often to request a qualified medical examination.
What are Qualified Medical Examinations?
According to California’s Department of Industrial Relations, a qualified medical examination is an assessment used to evaluate the disability status of injured workers. The evaluators who perform these examinations, including medical doctors, dentists, optometrists, psychologists, and podiatrists, must be certified by the Division of Workers’ Compensation’s Medical Unit. In California, this certification process involves meeting state-specific requirements for licensing and education, completing a report writing course, and passing the QME certification exam.
Qualified medical evaluators (QMEs) are intended to be neutral medical experts in a disputed claim. When litigating issues in a workers’ compensation case, judges will almost always follow and respect the opinion of the QME. Because this one doctor’s report holds so much weight, the process of selecting them is handled through a formal process known as a QME Panel.
When is a QME Panel Required?
In California, a QME panel is required when there is a dispute about the medical issues in your claim. This often happens when the insurance company disagrees with the findings of your primary treating physician. This panel is a randomly generated list of three independent doctors, from which a single evaluator will be selected for your case.
Common disputes that trigger a QME panel request include:
- Disagreements over your level of permanent disability
- Whether your injury was, in fact, caused by your work
- Whether you can return to work in some capacity
Once it has been determined that a QME panel is required, the selection process begins.
What is the QME Panel Process in California?
While QME procedures can vary based on whether or not you have representation, the process typically follows four steps:
Step 1: The QME Panel is Requested
After a medical dispute arises, either the injured worker, the injured worker’s representative or the insurance claims adjuster must formally request a QME panel. This request is submitted to the Division of Workers’ Compensation (DWC) Medical Unit. Attorneys typically submit this request through a dedicated online portal, while unrepresented parties are required to handle the process via mail.
Step 2: A List of Three Doctors is Issued
In response to the request, the DWC’s system randomly generates a list, or “Panel,” of three state-certified QME doctors from the requested medical specialty. The document includes the names and locations of the three physicians, and their brief professional biographies. If the unrepresented injured worker requested the Panel, the list is mailed to both the worker and the insurance claims adjuster. If the insurance claims adjuster or the injured workers representative requested the Panel, they are able to immediately print the list of QME’s from the online portal. The Panel must then be sent to the opposing party.
Step 3: Selection of the QME
If the insurance claims adjuster or the injured workers representative requested the Panel, the selection of the QME is a process of elimination. First, the injured workers representative “strikes” one name from the list of three, removing that doctor from consideration. Then, the insurance claims adjuster strikes one name from the remaining two doctors.
Step 4: The Final Doctor is Assigned
The doctor remaining on the list after each side has made a strike is officially assigned as the Qualified Medical Evaluator for the case. This is the physician who will conduct the independent medical examination and write the report that will be used to resolve the dispute.
Step 5: QME Selection by an Unrepresented Injured Worker
The unrepresented injured worker and of the insurance claims adjuster will both receive the requested Panel via USPS. Upon receipt the injured worker has only 10 days to select a QME from the list and schedule an exam. If they fail to do so the insurance claims adjuster has a right to select the QME from the Panel and set the exam for the injured worker.
Worried About the QME Process?
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What to Expect During Your Qualified Medical Examination
Unlike a regular treatment visit, the QME appointment is a medical-legal evaluation. That means that the doctor’s goal is not to treat your injury or provide ongoing medical care, but to provide an unbiased report to resolve the dispute. During the examination, the QME will review your relevant medical records, ask you detailed questions about how the injury occurred and your current symptoms, and conduct a focused physical examination.
To make sure your examination goes well:
- Be Honest and Consistent: Describe your injury and symptoms accurately. Do not exaggerate or downplay your pain. The doctor will have all your prior medical records, and inconsistencies can negatively affect your credibility.
- Stick to the Facts: Answer the questions asked. Avoid volunteering information about prior injuries unless asked, and do not complain about your employer or the insurance company.
- Bring Necessary Documents: Bring your ID and any relevant medical paperwork your attorney advises you to.
While being honest and organized is an excellent way to prepare for the examination, the most significant step takes place long before you enter the exam room: consulting with a legal representative. Choosing whether or not to consult with an attorney can be the deciding factor between a successful claim and a denied one.
How Legal Representation Impacts the QME Process
Although the official steps for selecting a QME are the same for everyone, the experience and outcome can be vastly different for those who have legal representation vs those who don’t. WIthout an experienced attorney, you face several risks:
- Missing the 10-Day Deadline: If you fail to select a QME and schedule an exam within 10 days of the panel being issued, the insurance adjuster gets to choose for you. They will select a doctor who is more likely to be favorable to the insurance company.
- Choosing the Wrong Doctor: An experienced attorney knows the reputations of the QMEs who appear on panels in your local area. They know which doctors are fair and which are biased toward insurance companies. Without this knowledge, you are making a blind choice.
- Failing to Properly Brief the QME: Attorneys know how to prepare a letter to the QME that summarizes your medical history and asks specific questions to frame the case properly. A worker on their own can easily leave out important details.
- Allowing a Biased Medical Record: An attorney ensures your entire relevant medical file is sent to the QME, not just the cherry-picked records the insurance company provides.
- Being Unable to Challenge a Bad Report: If the QME report is unfavorable, an attorney can request a supplemental report or schedule a deposition to question the doctor or submit additional evidence to rebut the opinion. An injured worker generally does not have the knowledge or ability to do this alone.
Experienced lawyers are familiar with most of the QMEs who appear on QME Panels. Without the attorney’s knowledge of which QME to strike, injured workers are put at an extreme disadvantage. It’s unfortunate, but QMEs have biases just like every other human being. Some are more empathetic and sympathetic to injured workers, while others are more likely to side with insurance companies.
A single misstep during the QME process can lead to the denial of your claim, resulting in the loss of medical care, significant reduction in disability benefits, and other consequences that can last for years. As such, it’s important to consult with professionals who are familiar with both the legal nuances of workers’ compensation and the qualified medical evaluators in your area.
Protect Your Claim with an Experienced North Bay Area Workers’ Compensation Attorney
The outcome of your entire claim can come down to the opinion of a single doctor, and facing the QME process alone gives the insurance company the advantage it needs to undervalue or deny your benefits. At the Law Office of Kneisler & Schondel, our job is to level the playing field. As experienced workers’ compensation lawyers in Sonoma County, we know how to select the right medical evaluator, manage deadlines, and build the strongest possible case to get you the benefits you deserve.
Don’t risk losing your claim
Contact our office now for a free consultation to discuss your case.
Qualified Medical Examination (QME) California Frequently Asked Questions
What is a QME Panel?
A QME panel is a list of three randomly selected, state-certified independent doctors. In a workers’ compensation dispute, both the injured worker’s side and the insurance company’s side get to remove (or “strike”) one doctor from the list. The last remaining doctor becomes the qualified medical evaluator for the case.
Can My Treating Doctor Be My QME in California?
No, they can not. By definition, a qualified medical evaluator must be an independent, neutral physician who is not your primary treating physician. The purpose of the QME is to provide an objective opinion to resolve a dispute between your doctor and the insurance company.
Who Pays for a QME in California?
The workers’ compensation insurance company is required to pay for the qualified medical examiner and report. Injured workers are not required to pay for any part of the evaluation. In most cases, only a single QME must be covered by the insurance company; however, additional panels may be requested.