This article is intended for anybody who is interested in learning about the role of a QME in California workers’ compensation.
What is a QME?
A California Qualified Medical Examiner (QME) is a doctor who has been certified to provide objective opinions on a work injury claim. In other words, a QME is a workers’ compensation expert and an impartial judge—he or she is supposed to review a work injury claim without any sort of bias.
The practical purpose of the California QME system is to offer timely evaluations of workers’ compensation claims that are being disputed by the involved parties—i.e., the injured worker and the insurance carrier.
Why does a panel QME get involved with a work injury?
A QME gets involved with a work injury because somebody is unsatisfied with the claim. For example, the patient might be unhappy with the outcome—maybe he/she believes that the impairment rating is incorrect, or his/her care got denied. Alternatively, the insurance carrier might believe that the patient’s physician failed to provide complete information on the claim. In either case, a QME can be called in to review the case.
What does this mean for me if I’m an injured worker?
If you’ve been hurt on a job, then you might be examined by a QME if an insurance carrier thinks that the your doctor has failed to provide complete information on the claim. If the QME finds that your doctor’s report on your claim was dramatically incomplete, then your impairment rating might change, as well as the amount of treatment that your insurance carrier will pay for.
Alternatively, if you’re unhappy with the outcome of your work injury claim, then you can call in a QME to review your case.
What’s the difference between an AME and QME?
A panel QME is distinct from an AME. An AME is an Agreed Medical Examiner that the injured worker and the insurance carrier agree to use to resolve disputes in the workers’ compensation case.
Are you a doctor who is considering becoming a QME?
If so, then congratulations and thank you. QMEs benefit the workers’ compensation system by providing unbiased opinions and bringing their expertise to bear on disputes related to work injuries.
Also, if you are QME, then you can increase business to your medical practice by building your reputation the eyes of attorneys, insurance carriers, and other stakeholders in workers’ compensation.
How to become a QME
If you are a medical provider who wants to become a QME in California, then visit this section of California’s Department of Industrial Relations website to find out when the next QME Competency Examination is taking place.
The examination is non-specialty specific—in other words, there are no questions about medicine on the exam. The medical doctors are board certified in a specialty, and must pass this test, in addition to completion of a 12 hour report writing program to become eligible to become a QME.
A Qualified Medical Examiner is not required to demonstrate competency in AMA Guides impairment rating as part of the certification process. Upon completion of the DWC requirements, the doctor becomes listed as available for performing QME exams in their listed medical board specialty. The QME must complete 12 hours of continuing medical education approved by the DWC every two years to remain active.
How a panel QME exam works—in detail
A panel qualified medical exam is a QME exam that is performed based on a choice of three examiners whose practice locations are nearest the injured workers’ zip code. The goal of the panel QME exam is to allow the parties access to objective examiners who will consider the dispute and offer an opinion, in hopes of resolving the issue and moving the claim along toward appropriate treatment, or settlement. The exam is to be scheduled within six weeks of the appointment call. This allows the insurance carrier time to get the chart records necessary to aid in the exam.
First the QME performs a history, physical examination and a review of medical records as provided by the insurance carrier. The QME then writes a standardized report that addresses the basic considerations of a workers’ compensation claim. The QME must address include: causation, permanent and stationary status, an impairment value calculation (if the case is found permanent and stationary), the need for ongoing treatment, and apportionment.
The DWC will recognize the length and complexity of the exam by designating Medical Legal (ML) codes to the title of the report. A QME examination is designated as a ML-102, ML-103 or ML-104. This designation is often included in the heading or title of the exam. The ML code designation is based on a combination of time and complexity of issues. The complexity issues may sometimes be referred to as “bona fide” issues. These are the issues that support the ML codes. A ML code may also have modifiers. These are codes that follow the ML designation.
The most common modifier is a -95, which designates the report as a panel select QME examination. The second being a -93, which indicates an interpreter was used during the interview of the QME exam. Together, the combinations of the ML designation, along with modifiers, communicate the complexity and circumstance of the examination to the reader.
The Qualified Medical Examiner is required to serve a copy of the QME report to the injured worker, the insurance carrier, and if permanent impairment or disability is address, to the local Disability Evaluation Unit (DEU) within 30 days of the appointment visit.
If there are no other issues to be resolved and the parties are satisfied with the QME opinion, the role of the QME may conclude. However, if further diagnostic testing or chart documentation is required, the QME may delay opinion pending the receipt of more information in the form of a supplemental report (ML-106). For more information on QMEs and Qualified Medical Exams, visit the California Division of Workers’ Compensation website FAQ or feel free to contact us—we love talking about it.