If you get injured on the job, you should be able to count on workers’ compensation to provide you with much-needed benefits that help keep you financially afloat while you recover. ‘Should’ being the keyword there because getting the benefits you need isn’t always easy. You and your physician may disagree about the care you need, or your employer may question whether you need treatment at all, which can lead to a neutral professional opinion request. In this case, you will need a QME or Qualified Medical Evaluator to help you resolve the dispute and get the treatment you deserve.
Summary:
- What is a QME?
- Who can be a QME?
- Why do you need a QME?
- QMEs vs Treating Physicians: Main Differences
- How to Read a QME: Extra Info
1. What is a QME?
QME stands for Qualified Medical Evaluator. A QME is a physician who evaluates your case when it isn’t clear which workers’ comp benefits you should receive based on your work injury. A dispute can arise if your employer or the insurance company doesn’t approve the treatment that your Primary Treating Physician (PTP) recommended.
The job of the QME is to examine you, evaluate you, and write a thorough medical report about your case. The report will define your eligibility for workers' comp benefits, so its accuracy is highly important.
QMEs usually include:
- Osteopathy doctors
- Chiropractic doctors
- Dentists
- Optometrists
- Podiatrists
- Psychologists
- Acupuncturists
2. Who Can Be a QME?
A QME is a doctor who has specifically trained to evaluate injured workers. They must meet educational and licensing requirements to qualify. Additionally, they need to pass a test and participate in continuing education courses that make them prove and improve their skills and knowledge. The advantage of QMEs is that they are supposed to be impartial when assessing an injury and offer a neutral opinion on the workers’ comp case.
QMEs can decide on aspects such as:
- Permanent Disability
- Medical treatment
- Disability status
- Work restrictions
- Whether the injury happened in the first place
3. Why Do You Need a QME?
Qualified Medical Evaluations are an important part of the workers' compensation process. They are meant to ensure that insurance companies treat injured workers fairly and impartially.
If the insurance denies your benefits or if you disagree with the benefits the insurance offers you, you can appeal to a QME. However, remember that a QME evaluation could either help or hurt your claim. It depends on what the evaluator and panel find relevant in your case.
Take into consideration that not every workers’ compensation case is approved. Sometimes, claims are denied for legitimate reasons, but sometimes, they are denied for unjust, unfair, and unlawful reasons. Unfortunately, some physicians may favor the insurance company.
On some occasions, you can find doctors who are committed to helping you recover from your work injury. But not all QMEs share this mindset. There are plenty of doctors who want to help the insurance company avoid paying your workers’ comp benefits.
In these instances, you need a neutral person to assist with the case, and that’s what QMEs are for. If both you and the claims administrator agree with the treating physician's report, there is no need to attend a QME evaluation.
4. QMEs vs Treating Physicians
The main difference between treating physicians and QMEs is that treating physicians attend to your case, but do not necessarily make lengthy reports or examine your medical history. They only want to assess your current situation and treat your injuries. On the other hand, QMEs are responsible for reviewing your medical history and assessing your condition, then they will compose detailed reports that summarize their findings.
A QME report is viewed as trustworthy because it contains information about your health and workers’ compensation status, two things that are difficult for a treating physician to determine. A physician can only give opinions on your health, but that’s it.
When you go to court, the judge must choose between the QME’s thorough report or a short-form report from the Primary Treating Physician (PTP). Typically, the judge will want to use the one with the most information on your case.
Extra Info: How to Read a QME Report
A QME is a doctor certified by the Division of Workers’ Compensation (DWC) to evaluate injured workers when there’s a disagreement about their condition. After examining you and reviewing your medical history, the QME issues a detailed report that provides their medical opinion. However, these reports are filled with technical language, legal terminology, and complex assessments, so it’s important to know what to look for—and where mistakes can occur.
To read a QME report, you’ll want to look for key components, such as:
- Injury description and history: This section outlines your account of the injury and the events leading up to it. Make sure your statements are accurately summarized. Any inconsistencies can be used to discredit your claim.
- Medical records reviewed: The QME should list all medical documents they reviewed. Missing records or reports could mean the QME didn’t have all the information necessary for a fair evaluation.
- Findings from the physical exam: Measurements, tests, and the doctor’s direct observations should be reviewed. Check whether these findings reflect your actual physical limitations and pain levels.
- Diagnosis and causation: The QME will offer a medical diagnosis and state whether the condition is work-related. Disputes often arise if the QME determines that your injury wasn’t caused by your job or during the course of your employment.
- Permanent and stationary (P&S) status: This determination means your condition has reached maximum medical improvement (MMI). Once you’re deemed P&S, the QME assigns a permanent disability rating, which directly impacts your benefits if any are granted.
- Apportionment: The QME may assign a percentage of your disability to non-work-related causes. A high apportionment to previous injuries or conditions can lower your compensation.
- Future medical care: If applicable, the QME will outline the type and frequency of future treatment you’ll need due to your work injury.
Why a Workers’ Comp Attorney Should Review the QME Report
Even small errors or omissions in a QME report can negatively impact your case. If you hire a workers’ compensation lawyer, they should be able to help you review the QME report line by line, correct inaccuracies, and challenge conclusions that are unfair or unsupported by evidence. If the report is unfavorable, you may be able to request a supplemental report or even obtain another evaluation under certain conditions.
Reading a QME report isn’t just about understanding what’s written; it’s also about knowing how it affects your claim. With legal guidance, you can gain that important understanding through your attorney’s representation.
Put Pacific Workers', The Lawyers for Injured Workers in Charge of Your Case
A qualified medical evaluator (QME) can help you by reevaluating your claim and getting the care you need. A QME can assess all types of injuries, from mild to severe. We know that understanding all of this is hard, especially if you are trying to get better from your injury.
But don’t worry, you don’t have to deal with the workers’ comp and QME processes alone. Pacific Workers', The Lawyers for Injured Workers can help you understand each step and fight to secure the workers’ comp benefits or settlement that you need. To get legal help with your Qualified Medical Evaluation or workers’ compensation claim in Northern California, reach out to us as soon as you can.
Start now by filling out an online contact form or by dialing (888) 740-6434 to speak with a member of our firm directly.