In the California workers’ compensation system, the Qualified Medical Evaluator (QME) process plays a crucial role in resolving medical disputes between injured workers and their employers or insurance companies.
When a worker is injured on the job, medical opinions are often needed to determine the extent of the injury, the necessary treatment, and the degree of permanent disability.
If there is a disagreement about any of these aspects, a Panel QME may be requested to provide an independent medical evaluation.
What is a Panel QME?
A Panel QME is a group of three independent medical evaluators from whom one is chosen to examine the injured worker. These evaluators are certified by the California Division of Workers’ Compensation (DWC) to perform objective medical assessments in workers’ compensation cases. The evaluation provided by the chosen QME plays a significant role in determining workers’ compensation benefits.
The Process of Obtaining a Panel QME
1. Request for Panel QME: If there is a dispute over the medical treatment or evaluation of the injury, either the injured worker, their attorney, or the claims administrator can request a Panel QME by submitting a Request for Qualified Medical Evaluator Panel (Form 105) to the DWC Medical Unit.
This request is typically made when the worker and the employer/insurance company have reached a disagreement about:
- The cause or extent of the injury
- The need for future medical care
- The worker’s permanent disability rating
2. Selection of a Specialty: The party requesting the panel must specify the medical specialty they believe is most appropriate for evaluating the injury. If the parties cannot agree on the specialty, the DWC Medical Unit will assign a specialty based on the nature of the injury.
3. Panel Issuance: The DWC Medical Unit then issues a panel of three QMEs. Each QME on the list is a physician in the specified specialty area, and their role is to act as neutral evaluators.
4. Choosing the QME: Once the panel is issued, the parties have ten days to select one of the three doctors. If the parties cannot agree, the injured worker has the right to strike one doctor from the list, and the claims administrator can strike another, leaving the remaining QME to perform the evaluation.
The QME Evaluation
Once the QME is chosen, the doctor will schedule an examination with the injured worker. The QME will review medical records, examine the worker, and may order additional tests. After the examination, the QME prepares a comprehensive report answering the specific medical questions that were in dispute.
The QME’s report typically addresses:
- The nature and extent of the worker’s injury
- Whether the injury is work-related
- The need for medical treatment
- Whether the worker is permanently disabled and, if so, to what degree
- The worker’s ability to return to work
This report is critical because it helps determine the level of benefits the worker will receive, including permanent disability payments and the scope of future medical care.
Implications of the QME’s Report
The QME’s report can have a significant impact on the outcome of a workers’ compensation case. Both parties may accept the findings of the QME or challenge them. If either party disagrees with the report, they can request a deposition of the QME to clarify or challenge the findings. In some cases, the matter may proceed to a workers’ compensation judge, who will make a final decision based on the QME’s report and other evidence.
Recent Changes and Controversies
Over the years, the Panel QME process has been subject to criticism. Some claim that the panels are often delayed, sometimes taking months to issue, which can slow down the resolution of disputes and the provision of benefits to injured workers.
Others argue that the process favors employers and insurance companies, as QMEs may have financial incentives to limit the scope of injuries or the extent of disability ratings. There have been legislative efforts to streamline the Panel QME process and improve its efficiency, including attempts to reduce the time it takes to issue panels and to address potential bias among QMEs.
However, challenges remain, and the process continues to evolve as part of California’s broader workers’ compensation reform efforts.
Conclusion
The Panel QME process in California workers’ compensation plays a vital role in resolving disputes over medical issues. While it offers a structured mechanism for obtaining independent medical evaluations, it is not without its challenges, including delays and perceived biases.
For injured workers navigating the process, it is essential to understand their rights, the steps involved, and the significant influence a QME report can have on their case.
