Answers to frequently asked questions about qualified medical evaluators (QMEs) for injured workers
The FAQs below apply to claims filed on or before Jan. 1, 2013. Updated information based upon the implementation of SB 863 and its changes to California's workers' compensation system will be available soon.
In addition to the FAQs below, employees may call 1-800-736-7401 to hear recorded information on a variety of workers' compensation topics 24 hours a day.
Employees may call a local office of the state Division of Workers' Compensation (DWC) and speak to the Information and Assistance (I&A) Unit for help during regular business hours, or attend a free seminar for injured workers.
Fact sheets and guides on a variety of topics can be found on the I&A Unit's Web page.
Topics covered in this FAQ include:
The Division of Workers' Compensation Medical Unit
Getting help with my claim
Treating physician as QME
Complaints regarding QMEs
Complaints regarding QME reports
Complaints regarding permanent disability ratings
Q. What is the DWC Medical Unit and what does it do?
A.The Medical Unit is a unit within the state Division of Workers' Compensation (DWC) that manages medical issues in workers' compensation. The DWC Medical Unit oversees medical provider networks (MPNs), health care organizations (HCOs), utilization review and medical treatment guidelines. The Medical Unit also appoints qualified medical evaluators (QMEs), spinal surgery second opinion physicians (SSSOPs) and independent medical reviewers (IMRs). These physicians help resolve medical disputes in the workers' compensation system by issuing medical opinions that can be used as evidence before the Workers' Compensation Appeals Board.
The Medical Unit also issues QME panels to injured workers and claims administrators.
You can reach the Medical Unit by calling 510-286-3700 or 1-800-794-6900.
Q. Who can give me information about my claim and help me understand the system?
A.Your claims administrator should advise you of your rights and the steps you will take to get medical care and other benefits you're entitled to under workers' compensation laws. The state Division of Workers' Compensation (DWC) also has an Information & Assistance (I&A) Unit that can assist with questions and understanding the system.
I&A officers work to ensure the law is followed and will assist you for free if you do not have an attorney. They will answer questions you have regarding rights and benefits. They will also help resolve conflicts that could arise between you and the claims administrator or your employer over your claim. If your work injury results in some permanent disability and you are ready to settle your claim, the I&A officer will review your settlement to make sure it's equitable. The majority of questions you might have regarding your claim can be answered by an I&A officer. You can attend a seminar for injured workers, held monthly at each of the DWC's 24 local offices, or call the I&A officer at your local office to schedule an appointment.
The Medical Unit will assist you with questions about the qualified medical evaluator process.
Q. What is a QME?
A.A qualified medical evaluator (QME) is a physician who evaluates you when there are questions about what benefits you should receive. A physician must meet educational and licensing requirements to qualify as a QME. They must also pass a test and participate in ongoing education on the workers' compensation evaluation process. If you have an attorney, you and your claims administrator might agree on a doctor to resolve medical disputes. This doctor is called an agreed medical evaluator (AME). An AME or a panel QME will be used to resolve medical disputes in your workers' compensation case.
Q. What is the difference between an AME and a QME?
A. If you have an attorney, your attorney and the claims administrator may agree on a doctor without going through the state system used to pick a QME. The doctor your attorney and the claims administrator agree on is called an agreed medical evaluator (AME). A QME is picked from a list of state-certified doctors issued by the DWC Medical Unit. QME lists are generated randomly. An AME can only be used if you are represented by an attorney. Once you see an AME you are not entitled to see a QME. An AME may be used regardless of the year of injury. An AME physician may be a QME, but does not have to be one.
Q. What is a panel QME?
A.In this context, the word panel means a list. A panel QME is a randomly generated list of three QME physicians issued to you when there is a question about whether or not your injury is work related, or if there is a medical dispute that hasn't been resolved by the treating physician's report. Whoever fills out the form to request the panel QME chooses the specialty of the doctors on the panel.
Q. Who completes the panel request form?
A.You will receive the panel request form from the claims administrator and are given the first chance to fill out and submit the form. If you do not submit the form within 10 days, the claims administrator will do it for you and will get to choose the specialty of the QME you'll see.
(Title 8, California Code of Regulations, section 30, Labor Code sections 139.2(h), 4061(d), 4062(b))
Q. I have two different problems from the same injury (for instance, a psychiatric and an orthopedic problem). May I request two panels, one psychiatric and one orthopedic?
A. The basic rule is that you get one. The claims administrator is only required to pay for one QME evaluation. The selected QME can get a consultation from another physician if there is a need for input from more than one medical specialty.
However, there are some circumstances where a workers' compensation administrative law judge, the Division of Workers' Compensation's executive medical director or a state information & assistance officer may request an additional panel. In those cases, a panel will be provided.
(Title 8, California Code of Regulations, section 32 (c), Labor Code sections 5703.5(a), 5703.5(b), 4063.3(i))
Q. Can I get a new panel because the physicians on the panel are too far away?
A.No. The Medical Unit cannot replace physicians based on distance from your address and cannot simply choose the physicians closest to you. By law, the QME panel process must be done randomly according to ZIP code. The claims administrator will pay your transportation costs to see the QME.
Q. The QMEs on the panel you issued are close to my home. However, can you give me a panel closer to work?
A.The law requires the Medical Unit to issue panels close to your residence. However, the DWC Medical Unit can issue a panel of QMEs using the ZIP code of your workplace if the claims administrator agrees to this request.
(Title 8, California Code of Regulations, section 31.5 (b) (2, Labor Code section 139.2 (h))
Q. Can I get a second panel if one or more of the QMEs are unavailable for over 60 days?
A.If one or more of the panel QMEs is unavailable to see you within 60 days of receiving the panel, the Medical Unit will replace those QMEs. The Medical Unit will verify that the physicians on the original list are not available before issuing a new panel.
(Title 8, California Code of Regulations, section 31.5 (a); 33 (c))
Q. The panel QME I want to see is unavailable for three months. Can I wait for three months to see this QME?
A.Under most circumstances you can choose to wait. However, if the claims administrator is sending you to a QME because they don't think your injury or illness was caused by work, you cannot wait. This is called seeing a QME to determine AOE/COE, which means determining whether your injury or illness is arising out of and occurring in the course of employment.
(Title 8, California Code of Regulations, section 33)
Q. I showed the panel of QMEs to my treating physician/friend/union representative and he/she does not think any of the physicians listed will give a fair report. Will the DWC Medical Unit issue a new panel?
A.No. The panel is randomly selected through a computer program. All the physicians on the panel have applied to the DWC Medical Unit to be QMEs and have met all the requirements to be a QME. Only the Workers' Compensation Appeals Board has the authority to determine that a QME is biased or unfair.
Q. I received a panel three weeks ago and didn't select a QME. The claims administrator selected a QME from the panel and made the appointment. Can they do that?
A. Yes. If you didn't select a QME from the panel within 10 days of its issue date, the claims administrator has the right to make the selection.
Q. I was issued a panel of orthopedists at the claims administrator's request. However, I want to see a chiropractor. Will you issue a new panel?
A. No. You had the first chance to send in the request form and to select the specialty of the QME. If you failed to make the request within the 10-day deadline, the claims administrator has the right to select the specialty of the panel.
Q. Is it possible to replace the physician due to his nationality/accent/age?
A.No. All the physicians on your panel have met the DWC Medical Unit's requirements to be a QME and are licensed to practice in California. The QME physicians on the panel are randomly selected.
(Labor Code section 139.2 (a)(1); 139.2(h))
Q. What happens when a physician on the QME panel is no longer a QME?
A.The Medical Unit will check its records to see if the physician is still an active QME. If not, this QME will be replaced.
Q. What if two of the QMEs listed are in the same office or medical group and I believe this does not really give me a choice of three different QMEs?
A.Under these circumstances the DWC Medical Unit will issue a second panel replacing one of the physicians.
(Title 8, California Code of Regulations, section 31.5 (a) (4))
Q. I have moved since the panel of QMEs was issued. Will the DWC Medical Unit issue a new panel closer to my new home?
A. Yes. The Medical Unit will issue a new panel closer to your new residence as long as you have not been seen by a QME doctor from the first panel.
(Title 8, California Code of Regulations, section 31.5 (a)(3))
Q. Do I have to go through the QME process if the claims administrator and I agree with the treating physician's report?
A.Not if you both agree and the treating physician's final evaluation is adequate. That means that if your case includes some permanent disability, the treating physician's report must be written correctly to ensure it is "ratable" by the Disability Evaluation Unit.
(Labor Code sections 4061(d), 4061.5)
Q. I moved out of California and would like to settle my case without going through the QME process. Is this possible?
A.If both you and the claims administrator agree with the treating physician's report there is no need to attend a QME evaluation.
Q. My QME evaluation was yesterday. How long does the doctor have to issue the report?
A. The QME has 30 calendar days from the date of the commencement of the exam to issue the report. There are three reasons a physician may request an extension:
- The physician requested you have medical tests and is awaiting results
- The physician requested a consultation and is awaiting the consultant's report
- The physician has a "good cause" for an extension. A good cause is a medical emergency of the evaluator or the evaluator's family, death in evaluator's family, natural disaster or other community catastrophes that interrupt the operation of the evaluator's office. The computer breaking down or a staff member quitting is not considered good cause. Extensions for good cause may not exceed 15 days from the date the report is required to be served.
The physician may not request an extension because the claims administrator failed to provide your medical records or past medical tests. If the report is going to be late, the physician must file a time frame extension request with the DWC Medical Unit and send a copy to the claims administrator and to you. This must be filed five days before the report is due. (Title 8, California Code of Regulations, section 38)
Q. I just received the QME report. What happens next?
A.If you don't have an attorney and permanent disability is the disputed issue, the QME will send a copy of the report to the claims administrator, to the Division of Workers' Compensation Disability Evaluation Unit (DEU) and to you. The DEU should issue a rating within 20 days. If a rating is not issued within 20 days, you may ask the claims administrator if they would rate the report rather than waiting for the DEU to issue a rating. If you have questions on the rating issued by the claims administrator, you may discuss the rating with a DWC information & assistance officer. Once a rating is obtained, you may begin discussing settlement of your case with the claims administrator. If you have questions on the settlement of your claim or just want to make sure your case is being handled correctly, contact your local DWC information & assistance officer. (Labor Code sections 4062 (c); 4061 (i))
If you have an attorney and permanent disability is the disputed issue, the QME will send a copy of the report to both your attorney and the attorney for the claims administrator. If a permanent disability rating is required, a copy of the report will be sent to a disability rater by either your attorney or the attorney for the claims administrator. Your attorney should advise you about all the steps in the process.
Q. I need another evaluation. Should the original QME do it? What if that physician is no longer performing QME evaluations?
A.The second evaluation should be done by the same QME. The exceptions to this rule are:
- The physician is no longer available
- The physician became the treating physician after performing the QME evaluation
- A workers' compensation administrative law judge decides you should have a new evaluation with a different QME.
If any exception applies, you may begin the QME request process again and you will receive a new panel.
(Labor Code sections 4062.3(j); 4067)
Q. Why are my medical and non-medical records sent to the QME?
A. These records give the QME a history of your injury. The physician's records indicate the diagnosis and treatment received to date. Test results, such as MRIs, are forwarded so that the QME will not have to duplicate the tests. Medical records about treatment prior to the injury are often sent to help determine how much of the permanent disability is due to this injury and how much may be due to a prior injury or accident. Non-medical records, such as personnel records or films, are sent to provide information regarding the injury to the QME physician.
Q. What non-medical and medical records are sent to the QME? Can anyone object to certain records being sent to the QME for review?
A. The claims administrator receives, on an ongoing basis, all the treating physician's reports, copies of x-ray results, and may obtain old medical records that relate to the current injury. All these are considered medical records. You do not have the right to object to any medical records being sent to the QME. (Labor Code section 4062.3 (b))
Non-medical records may include personnel records or films.
Once you make the QME appointment, the physician has five days to send the QME appointment notification form to the claims administrator advising them of the appointment. The claims administrator is required to send you a copy of everything they plan to send to the QME physician 20 days prior to sending the records to the QME. You are also required to send any information (letters from friends, personal records) you are planning to send to the QME to the claims administrator 20 days before you send it to the QME. Both you and the claims administrator (or your respective attorneys) have 10 days to object to any non-medicalrecords being sent to the QME. There is no form for this objection. Whoever is objecting simply writes a letter to the other party. If either you or the claims administrator does not follow the 20-day rule, the wronged party has the right to cancel the evaluation.
(Title 8, California Code of Regulations, section 35, Labor Code section 4062.3 (b))
Q. The QME evaluation is next week, but I have not received the medical records and neither has the QME. What should be done?
A.There are two options:
- You may cancel the appointment, call the claims administrator or treating doctor to obtain the records, and then reschedule the appointment
- You may keep the appointment and have the claims administrator send the records to you and then to the QME after the evaluation. Some QMEs don't want to do an evaluation without the records, so check with the QME's office to see if the appointment should be rescheduled.
Q. What should I do if the claims administrator is objecting to one of the QMEs on my panel because the doctor treated or evaluated me, is in the same office as my treating physician or is my primary treating physician?
A. Any physician who has served as the primary treating physician for this injury may not be your QME. However, the Medical Unit will not replace a QME just because you saw him in the past for some other problem. The QME would only be excluded if he/she treated you for this injury. The Medical Unit will issue one new QME name to replace the primary treating physician. A QME is required to disqualify himself when he has served as your primary treating physician.
Q. How should I complain about a QME?
A.Complaints should either be put in writing and sent to the DWC Medical Unit (Attn: Complaint Unit) P.O. Box 420603, San Francisco, CA 94142, or you can make an anonymous complaint by calling the Medical Unit's hotline at 1-800-999-1041. The Medical Unit prefers to have your name and address or phone number so that it can reach you if there are questions.
Q. The QME did not issue the report and it's been over two months. What recourse do I have?
A. First, the Medical Unit will check to see if the QME requested an extension. If an extension was not requested or if the extension requested was denied, you can continue to wait for the QME report to be issued if you wish. If you don't want to wait, the Medical Unit will issue a new panel. In this case, either the claims administrator or you should contact the original QME and tell him not to issue his report as his bill will not be paid.
(Title 8, California Code of Regulations, sections 38, 60 (b) (4), Labor Code section 4062.5)
Q. The QME has not issued the requested supplemental report and it's been over three months. What recourse do I have?
A.The QME should issue the supplemental report within 60 days. Contact the DWC Medical Unit, your attorney or a DWC information & assistance officer for help.
Q. What can I do if the QME did not address all my medical issues?
A. If you don't have an attorney and the DEU summary rating has not been issued, you may write to the QME and ask that he/she issue a supplemental report. Remember that 20 days prior to sending the letter to the QME, you must send a copy to the claims administrator.
If a summary rating has already been issued, you have 30 days to file a "Request for Reconsideration of the Summary Rating," (DEU form 103) asking that the QME issue a supplemental report. Another option is to contact a DWC information & assistance officer and ask for help resolving the problem.
(Title 8, California Code of Regulations, sections 10164 and 10160, 35, Labor Code section 4062.2 (e, f))
Q. I disagree with the QME's opinion on my permanent disability and my ability to perform the job. What recourse do I have?
A.If your primary treating physician and the QME have differing opinions on your permanent disability and ability to perform your job, and if you agree with the treating physician's report, while the claims administrator agrees with the QME report, you may either negotiate a compromise with the claims administrator or contact a DWC information & assistance officer to discuss your options.
(Labor Code sections 4061(d), 4062(a), 4062.9, 4064)
Q. Who do I contact if I disagree with the permanent disability rating?
A.If either you or the claims administrator disagrees with the DEU summary rating, the "Request for Reconsideration of the Summary Rating" must be sent to the DWC administrative director using DEU form 103 within 30 days. There are only four reasons to request reconsideration of the summary rating:
- The QME failed to address all issues
- The QME failed to completely address all issues
- The DWC Medical Unit's procedures were not followed by the QME
- The rating was incorrectly calculated.
If it has been over 30 days since the rating was issued or if the reason you disagree with the rating does not fall into one of the four categories above, contact a DWC information & assistance officer to discuss your options.
(Title 8, California Code of Regulations, sections 10164)
Q. I (or the claims administrator) believe, based on the QME's report, that the QME needs to consult with a physician in another specialty but the QME disagrees. What recourse do I have?
A.If either you or the claims administrator think the QME has not consulted with a physician whose expertise is necessary for a complete and accurate evaluation, you may write to the DWC Medical Unit and request that the DWC Medical Unit direct the evaluator to consult with a physician in an appropriate specialty.
Q. I filled out DEU form 103, the "Request for Reconsideration of Summary Rating," but have not heard anything. What should I do?
A. For information on the status of the rating reconsideration, call the Division of Workers' Compensation Rating Reconsideration Unit at (510) 286-7100.