Understanding The QME/AME Process
According to the California Department of Industrial Relations, “[q]ualified medical evaluators (QMEs) are qualified physicians who are certified by the Division of Workers’ Compensation – Medical Unit to examine injured workers to evaluate disability and write medical-legal reports. The reports are used to determine an injured worker’s eligibility for workers’ compensation benefits. QMEs include medical doctors, doctors of osteopathy, doctors of chiropractic, dentists, optometrists, podiatrists, psychologists and acupuncturists.” These doctors cannot provide any treatment.
There is a formal legal process required to obtain a QME. Either side can initiate the process by objecting to a treating doctor’s report on an accepted claim, or by the injured worker demanding a comprehensive medical evaluation on a case where all benefits are denied and a medical opinion is needed to determine eligibility for benefits. The law requires written notice be given of the objection or demand, and that the parties wait 10 business days plus another 5 calendar days (or more if a party is out of state) before requesting 3 names from the Department of Workers Compensation Medical Unit . After the names are provided, each side gets to strike one name from the panel, and the injured worker will see the remaining doctor. That doctor must be available to see the injured worker within 60 days of seeking the appointment, or a new panel may have to be obtained. This requirement often results in delays, especially during the pendency of the Covid-19 pandemic when many doctors have restricted their practices.
Sometimes, instead of a QME, an Agreed Medical Evaluator (AMEs) is used. An AME can only be used in cases where the injured worker is represented by an attorney and agreement is achieved with the insurance company on a particular physician in whom both sides have confidence to determine the same issues. One major difference between an AME opinion and a QME opinion is that a judge is instructed to give the AME opinion “great weight” in resolving disputes, whereas the QME opinion is just one more expert opinion in the case.