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Employees may face many hurdles after a workplace injury. For one, workers’ compensation insurance adjusters may require additional documentation or medical evaluations before approving benefits. They may request that injured employees submit to an exam with a Qualified Medical Examiner.
A Qualified Medical Examiner (QME) evaluates injured workers to test the validity and cause of their injuries. Submitting this exam may seem unnecessary, but getting a favorable decision from this doctor is critical to your case.
Understanding this process is essential for injured workers. Knowing what to expect and how to prepare for the exam can make a difference regarding your workers’ compensation claim. In some cases, hiring an experienced California workers’ compensation attorney can help you navigate the process and safeguard your right to benefits following a job-related injury.
The attorneys at Arash Law are available to assist injured workers across California. We have years of experience helping individuals pursue the workers’ compensation benefits to which they may be entitled. Contact us at (888) 488-1391 or chat online to schedule a free, no-obligation case evaluation.
What Do QMEs Do?
A Qualified Medical Examiner (QME) acts as a neutral evaluator when there is a dispute between the injured worker and the workers’ compensation insurance adjuster.
The QME provides a physical examination of the injured employee. As a part of their overall evaluation, the QME will review the worker’s current physical condition and medical records.
After the examination, the QME will issue a report containing their expert opinion about whether the injury exists, the extent of the injury, whether the worker is disabled, a disability rating, and the estimated cost of treatment.
The QME’s opinion will either agree or disagree with your primary care physician. The report helps resolve disagreements between the employee and the workers’ compensation insurance adjuster regarding the employee’s injuries and medical issues.
Who Can Serve As A QME?
A QME must be a board-certified physician and carry a medical specialty. The QME must be a licensed physician and certified by the California Division of Workers’ Compensation Medical Unit.
California keeps a list of QMEs. An injured worker must choose from a list of three doctors provided to each side within ten days of receipt.
A QME can be a medical doctor, psychologist, dentist, or another qualified medical professional.
Can I Replace A QME?
Yes, there are situations when an injured worker can replace a QME. An injured employee might request a new list of QMEs if the current QMEs violated these procedural rules:
- Two QMEs practice medicine in the same office or under the same medical group.
- The QME cannot timely complete the expert medical report.
- The unqualified QME appears on the first and second lists given to the injured worker.
A workers’ compensation insurance adjuster may also request a new QME if certain procedural issues arise. In these cases, both sides can seek a fair and impartial evaluation.
If you need a new QME, you may consult an experienced attorney to learn how to protect your rights. A lawyer can help you choose a new QME who will remain neutral when rendering their opinion.
What Happens During A QME Examination?
You may wonder what to expect during a QME examination. A QME examination is unlike a typical doctor’s appointment because you are meeting with the physician to provide an independent medical evaluation related to your claim.
During your exam, the QME will evaluate your condition. They may ask about preexisting conditions and other injuries. The QME will review your medical records since the accident to determine whether your current condition is connected to your work-related incident or influenced by other factors.
The results of your QME examination are critical to the outcome of your case. Because the QME’s opinion carries significant weight in the claims process, an unfavorable report from the QME may affect your eligibility for certain workers’ compensation benefits.
Being well-prepared can help you describe your condition and symptoms to the QME.
How To Prepare For My QME Examination
Preparation helps you present your case clearly and thoroughly. Being well-prepared allows you to provide complete information about your condition and injuries.
Injured employees may choose from a list of QMEs provided to each side of the case. The employee must choose a doctor from the provided list within ten days of receipt. Failure to decide gives the workers’ compensation adjuster assigned to your case the option to choose a doctor for you.
It is important to participate in the QME selection process when possible. While QMEs are required to be neutral, having input in the selection allows you to choose from the available options.
It may be wise to always prepare for your appointment, regardless of the QME assigned. Some practical steps you can take to prepare for your examination include the following:
Make A List Of Your Injuries
List each injury you suffered because of the accident. Your examination is your chance to highlight the severity of your harm and explain it to the doctor. Rate your injuries. You may also describe the pain level of each injury using a simple 1–10 scale.
Create A Timeline Of Your Injuries
Creating a timeline of your injuries helps you tell your story thoroughly to the QME. Start with the details of the day the accident happened until you visited the QME.
Keep A Journal Of Your Symptoms
Journaling your symptoms is a great way to track your physical and mental condition after a workplace accident. In addition to your primary symptoms, telling the QME about your emotional well-being and secondary symptoms is valuable. Examples of secondary symptoms injured employees may face include anxiety, panic attacks, depression, sleep disturbances, etc.
Research Your QME
It can be helpful to research your QME. Researching their medical specialty and professional experience can help you feel more prepared and informed for the evaluation. Preparedness contributes to a more effective examination.
Bring A Loved One To The Exam
Showing up to the QME exam prepared is essential. Bring pertinent medical records with you to your visit. Also, having a family member or friend familiar with the accident and your injuries can be helpful. Your loved one can help explain the extent of your injuries effectively to the QME.
What Information Will The QME Need?
Your QME needs the following Information:
- Details about current and previous injuries.
- Current and past medications.
- Pain levels.
- Limitations on your ability to perform professional or leisure activities.
- Current symptoms.
- Details about the accident, such as when and where it occurred, etc.
Who Pays For A QME Examination?
Many injured workers worry about the expenses associated with pursuing their claim, and the anxiety about paying for the QME exam is no exception. Fortunately, state workers’ compensation benefits typically cover the cost of the examination. Injured workers do not need to worry about that cost.
How Long Does It Take To Receive A QME Report?
After the examination, you will anxiously await the results. California law requires a QME to issue a report containing their opinions about the extent and cause of the injury, disability rating, and the anticipated cost of treatment within 30 calendar days of the examination.
A 15-day extension is available for a QME under strict circumstances. Situations in which a QME may have more time to issue their report include the following:
- The QME is awaiting the lab results to make an accurate diagnosis and provide an expert opinion.
- The QME consulted with another medical professional, and they are waiting for contact from them.
- There are other reasonable causes for delay, including family death, natural disasters, medical emergencies, etc.
Are QME Examinations Beneficial To Injured Workers?
Submitting to a QME exam can feel like a complex process, but it plays an important role in resolving disputes regarding a work-related injury. The QME evaluation offers an independent medical opinion that helps clarify the cause and extent of the injury.
However, if the worker’s compensation insurance adjuster decides the employee’s injury is not covered under the policy, getting a second opinion may benefit the employee.
What Can I Do If I Disagree With The QME’s Findings?
The QME’s opinion carries much weight in resolving your workers’ compensation claim. If you receive an unfavorable report, it can seem like it is the end of the road for your injury claim. However, consulting an experienced workers’ compensation attorney may help you explore your options.
How Can A Workers’ Compensation Attorney Help Me?
Hiring an attorney when you have a legal issue can help protect your rights. After a workplace injury, your attorney can help you protect your access to benefits. If you receive an unfavorable QME report, your attorney can file an appeal.
File A Complaint
If you have a complaint regarding the results of your QME, you can file a complaint with the California Division of Workers’ Compensation Medical Unit. Your written complaint must contain your name, address, and other contact information. File the complaint within 30 days of receiving the QME’s report.
An experienced attorney can help you file a Request for Reconsideration of the Summary Case. This document must include your reasons for the request, which can include:
- The QME did not follow every Medical Unit procedure.
- An allegation that the QME failed to address each pertinent issue.
- A claim that the QME did not address each issue entirely and adequately.
Injured workers can call 1-800-999-1041 for questions and send written complaints to:
- DWC Medical Unit
Attn: Complaint Unit
San Francisco, CA 94142
Filing An Appeal
An injured worker who received a negative QME report may file an appeal with the Division of Workers’ Compensation. The DWC will send a letter confirming your appeal and your case number.
Filing an appeal can get complicated. Your attorney can assist you with procedural requirements to help prevent delays or dismissal based on technical grounds.
Getting A Hearing Date And Trial
After filing your appeal, the division will assign a hearing date to your case. During the hearing, each side will present its evidence to a judge. The judge will also encourage both parties to explore possible settlement options. The case is scheduled for trial if the claim does not reach a settlement during the hearing.
Attorneys can support injured workers through effective representation due to their training in presenting facts clearly and concisely. Having an attorney may help improve your chances of effectively navigating the claims process after a job-related injury.
Contact Arash Law’s Workers’ Compensation Attorneys
If you suffered a workplace injury, contact the legal team at Arash Law. Our California workers’ compensation attorneys understand the importance of accessing benefits after an on-the-job injury. We are committed to guiding injured workers through the process of pursuing the benefits they may be entitled to under the law.
Having an attorney present before meeting with a Qualified Medical Examiner can be beneficial. The doctor’s opinion that evaluates your injuries may significantly affect your case. A workers’ compensation attorney will help you make vital medical decisions, including which QME to visit.
You may have the right to seek experienced legal representation after a workplace injury. Our legal team offers representation on a contingency basis, meaning no upfront fees. However, certain case-related costs may still apply.
The attorneys at Arash Law, managed by Arash Khorsandi, Esq., are available to discuss your situation. Contact us at (888) 488-1391 or through our online chat to schedule a free, no-obligation case evaluation.
