The QME Process

In a Workers’ Compensation case, it is likely that you will be evaluated by a Qualified Medical Examiner (QME). But what exactly is a QME and why does it matter? Selecting the right QME, as it turns out, can have a major impact on your Workers’ Compensation claim.

What is a QME?

A QME is a physician who is certified by the Division of Workers’ Compensation (DWC) Medical Unit to examine and evaluate an “applicant’s” disability and write medical-legal opinions. An applicant is the party that opens a case at the local Workers’ Compensation Appeals Board by filling out an application for adjudication of claim after they suffer a work-related injury.

The purpose of the QME is to provide a neutral evaluation of an applicant’s injury and help resolve any dispute between the applicant and the Workers’ Compensation insurance carrier over whether an applicant should receive benefits.

How do you start the QME process?

Either you, your attorney if represented, or the Workers’ Compensation insurance claim’s administrator can request a QME. You can fill out a QME request form obtained from the DWC website. Alternatively, you may receive a QME request form directly from the claim’s administrator.

Who Picks the QME?

Whoever fills out the QME request form decides the medical specialty of the QME. The medical specialty chosen for the QME should be related to the injury or illness. For example, if a person suffered a broken ankle injury and there is a question about how severe the injury is, the specialty of the QME may be an orthopedist. However, the specialty of the QME that you should see is not always an easy answer. This is one important area where having an attorney to help with the process is essential because your attorney will pick the specialty most beneficial to you to maximize the benefits you receive.

What is a Panel QME?

When a QME is requested, the DWC Medical Unit randomly generates a panel of three approved QMEs in the requested medical specialty. You then have ten days from when the list is generated to select one of the doctors on the list, inform the insurance company who is selected, and make an appointment. If the deadline is missed, the insurance company has the right to select the QME and make an appointment. This is important because the adjuster will likely pick a QME that is more biased toward the employer and may not have your best interests in mind.

What Does the QME Do?

The QME will receive a complete copy of your medical records from the insurance provider. The QME will then take a history of your injury and do a physical examination. From this, the QME will generate a report addressing the cause of injury, your disability, treatment needs, and, if your injury is stable, a calculation of your permanent impairment or disability.

What Happens After the QME Writes a Report?

The QME report is then used to determine a permanent disability rating. A rating is a percentage that estimates how much your disability has impacted your future earning capacity. If the rating determines that you have ratable permanent disability, then you should receive permanent disability award and permanent disability benefits. After you receive a rating, your attorney can start working on a settlement offer to present to the defendant.

Why does a QME matter?

A QME is supposed to be a neutral party; however, not all QMEs are created equally. Rather, some are more conservative and thus biased toward an employer. The QME ultimately issues an opinion as to an applicant’s disability status. This is why choosing the right QME can have a major impact on your case because it directly influences the benefits you may be entitled to receive.

Why Do I Need a Workers’ Compensation Attorney?

A Workers’ Compensation attorney will be highly knowledgeable in the QME process, including knowing what specialty to choose and what doctors on the list are more favorable to you. If you are unrepresented and do not select a QME, the insurance carrier will choose a doctor for you, which will often result in being evaluated by a physician that will be more favorable to the insurance company. That is why having an attorney knowledgeable in the process will maximize the benefits you may receive.

The QME process can be very confusing. Mastagni Holstedt, A.P.C. can help you navigate this complicated process. Workers’ Compensation consultations are complimentary of charge.