I Don’t Get the QME Process in Workers’ Compensation for Employees. Why Do I Need to See a QME?

Employees can face many hurdles after a workplace injury. For one, worker’s compensation insurance adjusters will not hand over benefits easily. Worker’s compensation insurance adjusters often 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 worker’s compensation claim. Hiring an experienced California worker’s compensation attorney is the best way to protect your access to benefits after a job-related injury.

The attorneys at Arash Law, founded by famous attorney Arash Khorsandi, Esq., are here to help. We have spent years helping injured California workers get the worker’s compensation benefits they deserve. Contact us today at (888) 488-1391 or chat online to schedule a free no-obligation case evaluation.

What Do QMEs Do?

What Do QMEs DoA Qualified Medical Examiner (QME) acts as a tie-breaker when there is a dispute between the injured worker and the worker’s 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 injuries, 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 should resolve disputes between the employee and the worker’s compensation insurance adjuster about your 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 Worker’s 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 worker’s compensation insurance adjuster can also request a new QME. Any time an adjuster chooses the QME, the worker is vulnerable to encountering a doctor likely to render a favorable decision for the employer.

If you need a new QME, consult an experienced attorney to learn how to protect your rights. An attorney will help you choose a new QME that 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 for a purpose.

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 rule out the possibility that another condition or illness caused or exacerbated your injuries.

The results of your QME examination are critical to the outcome of your case. Because the QME’s opinion is about the crux of the claim, an unfavorable report from the QME can mean losing access to worker’s compensation benefits.

Preparing for the exam is the best way to get a favorable QME report.

How to Prepare for My QME Examination

Preparedness creates the best QME report outcome. The more prepared you are, the greater the chances of worker’s compensation insurance covering your claim.

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 worker’s compensation adjuster assigned to your case the option to choose a doctor for you.

It is risky letting the worker’s compensation adjuster decide the QME. While QMEs should be neutral, some doctors are biased toward the employer. If you encounter a biased doctor, you may receive an unfavorable result.

It will be best to always prepare for your appointment, despite the QME assigned. Some practical steps you can take to be the most prepared 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. When you seek the QME, be ready with an injury rating from 1-10.

Create a Timeline of Your Injuries

Creating a timeline of your injuries is an excellent way to ensure 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. Your research may expose potential bias that your doctor may have towards your employer. While a QME should remain neutral, there are instances when their opinion includes some bias against the employee. Preparedness helps reduce the chance of an unfavorable report.

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, like when and where it happened, 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 worker’s compensation insurance pays for the expense 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 to a QME under strict circumstances. Situations in which a QME may have more time to issue their report include the following:

  • The QME is waiting for the lab results to make an accurate diagnosis and expert opinion.
  • The QME consulted with another medical professional, and they are waiting for contact from them.
  • There is another reasonable cause for delay, including a family death, natural disaster, medical emergency, etc.

Are QME Examinations Beneficial to Injured Workers?

Submitting to a QME exam can feel cumbersome. If the worker encounters a doctor with a bias toward their employer, the employee may feel like the exam is only a barrier to receiving worker’s compensation benefits.

However, if the worker’s compensation insurance adjuster decides the employee’s injury is not covered under worker’s compensation insurance, getting a second opinion benefits the employee.

A QME evaluation is a convenient way to resolve questions about the cause of the injury. The QME can offer a second and more helpful opinion to resolving an injured worker’s claim.

What Can I Do If I Disagree with the QME’s Findings?

The QME’s opinion carries much weight in resolving your worker’s compensation claim. If you receive an unfavorable report, it can seem like it is the end of the road for your injury claim. However, there is hope. If you receive a negative QME report, your next best step is to hire an experienced worker’s compensation attorney.

How Can a Worker’s Compensation Attorney Help Me?

Hiring an attorney if you have a legal issue is the best way to protect your rights. After a workplace injury, your attorney will help you protect your access to benefits. If you receive an unfavorable QME report, your attorney can help you file an appeal.

File a ComplaintFile a Complaint

If you have a complaint regarding the results of your QME, you can file a complaint with the California Division of Worker’s 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:

  • That 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 Worker’s Compensation. The DWC will send a letter confirming your appeal and your case number.

Filing an appeal can get complicated. Your attorney can help ensure that you comply with technicalities and avoid the dismissal of your claim on technical grounds.

If you receive an unfavorable report from the QME, there is still hope for your claim. Contact an injury attorney to discuss your options and how they can assist you during your appeal.

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 try to assist the parties in settlement negotiations. The case is scheduled for trial if the claim cannot settle for the hearing.

Attorneys benefit injured workers with their representation because of their training in persuasively presenting the facts of their client’s case. Having an attorney increases your chances of gaining access to your worker’s compensation benefits after a job-related injury.

Contact Arash Law, founded by Arash Khorsandi, Esq., Today

If you suffered a workplace injury, contact the legal team at Arash Law, spearheaded by Arash Khorsandi, Esq., Our California worker’s compensation attorneys know the importance of accessing benefits after an on-the-job injury. We want to help you get what you deserve after an accident.

Having an attorney before meeting with a Qualified Medical Examiner will be best. The doctor’s opinion that evaluates your injuries can make or break your case. A worker’s compensation attorney will help you make vital medical decisions, including which QME to visit.

You deserve a skilled advocate after a workplace injury. The legal team at Arash Law by Arash Khorsandi, Esq. provides the expert representation you need with no up-front costs and no fee unless we win your case.

The attorneys at Arash Law, managed by Arash Khorsandi, Esq., are here to help. Contact us today at (888) 488-1391 or through our online chat to schedule a free no-obligation case evaluation.

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DISCLAIMER: Information provided on this blog is not formal legal advice. It is generic legal information. Under no circumstances should the information on this page be relied upon when deciding the proper course of a legal action. Always obtain a free and confidential case evaluation from a reputable attorney near you if you think you might have a personal injury lawsuit.

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