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This blog was updated on 05/17/2025
As an injured worker, you must know that a Qualified Medical Evaluation (QME) plays a significant role in your workers’ compensation case. Especially when there’s a dispute about the nature or extent of your workplace injury or illness.
If your employer’s insurance company questions the original medical assessment, you may be required to undergo a QME conducted by a state-certified, impartial physician.
A QME is often required to assess the severity of an injury, the level of disability, and the appropriate treatment plan.
What is QME and when is it required?
A QME is a comprehensive medical evaluation conducted by a doctor who is not your treating physician. The purpose of a QME is to provide an impartial, objective medical opinion on various aspects of an injured workers’ claim. These evaluations are often triggered when:
There is disagreement over the diagnosis or treatment plan.
QME’s ensure fairness in resolving conflicted opinions regarding the injury and treatment.
The QME helps determine eligibility for benefits when the insurance disputes the claim.
Treatment recommendations are given for ongoing care.
You’ve reached maximum medical improvement (MMI), but disability remains uncertain.
This evaluation ensures that all parties receive a fair and accurate assessment of the medical aspects of a claim.
The QME Process Explained
Understanding how the QME process works helps prepare you for what’s ahead.
How is a QME Scheduled?
Once a dispute arises, the Division of Workers’ Compensation assigns a QME from a randomly selected list. You’ll be notified of the appointment by mail. If you are represented by an attorney, your legal team will also be informed and in some cases, you might be given an Agreed Medical Evaluator (AME).
What Documents Are Reviewed?
The QME doctor examines your:
Medical records
Injury reports
Diagnostic tests
Letters from attorneys or insurance adjusters
Everything related to your injury
QME Report:
After the examination, the QME will produce a report that includes their findings. This report is critical in determining the course of action in a workers' compensation claim, including disability ratings and medical treatment plans.
Dispute Resolution:
The report from the QME is often used in court or in negotiations to settle disputes. The findings will be weighed heavily in the determination of whether the worker’s injury is compensable, how much compensation they are entitled to, and whether further treatment is needed.
Why do QME’s Matter in Workers’ Compensation Cases?
The QME’s findings are legally significant. The report produced can:
Confirm or deny your eligibility for benefits.
Influence the level of disability you’re assigned.
Serve as a primary piece of evidence in a workers’ compensation hearing.
Risks and Challenges of the QME Process
While QMEs are meant to be impartial, there are challenges:
Influence from Insurance Companies: Since insurers can frame the questions, they may lead to biased assessments.
Lack of Physician-Patient Privilege: The QME doctor is not bound by confidentiality rules. Anything you say may be used in court.
Perceived Bias: Some claimants feel that QMEs may not be truly neutral, especially if doctors regularly perform evaluations for insurers.
How to Protect Your Rights During a QME
Protecting your rights during this process is crucial.
Having the Right Attorney can Make All The Difference.
A workers’ compensation attorney can help by:
Preparing you for the QME.
Requesting corrections or clarifications.
Challenging biased reports in court.
Helping you select a great QME Doctor.
Common Mistakes Injured Workers Make During QME’s
Avoid these pitfalls:
Disregarding the importance of the QME report
Sharing too much personal information with the QME doctor
Assuming the doctor is on your side
FAQ’s About Qualified Medical Evaluations
1. Can I choose my own QME doctor?
Not directly. A list of QME’s is randomly generated, and you can select from that list.
2. Is the QME doctor on my side?
No, they are neutral and not your treating physician. Their role is to provide an unbiased evaluation.
3. Can I bring a witness to my QME appointment?
In California, you may be allowed to bring a non-lawyer witness, such as a translator or chaperone.
4. What if I disagree with the QME report?
You can contest the findings with the help of your attorney and may request a second opinion.
5. Do I have to pay for the QME?
No, the cost is usually covered by the employer’s workers’ compensation insurance.
6. How long does it take to receive the QME report?
Usually within 30 days after the evaluation.
Conclusion
Qualified Medical Evaluations are more than just routine assessments; they can make or break your workers’ compensation case. Understanding how they work, recognizing potential pitfalls, and having legal representation can help you protect your rights and secure the benefits you deserve.
If you would like a Free Consultation, contact Pacific Workers at 800 606 6999.
About the Author
Bilal Kassem is the president and co-founder of Pacific Workers. With an exceptional 98% success rate at Pacific Workers, he is on a mission to educate and support every injured worker across California. A key aspect of Bilal’s advocacy lies in guiding injured workers through the complexities of the Qualified Medical Evaluation (QME) process. Bilal ensures our clients understand how to navigate QMEs strategically.