Answers to frequently asked questions about qualified medical evaluators (QMEs) for insurers
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.
Topics covered in this FAQ include:
Q. What are the new requirements to become a QME?
A. With the passage of AB776 starting on January 1, 2000, all physicians seeking a new appointment as a QME must take a 12 hour course on medical-legal report writing. Medical Doctors and Doctors of Osteopathy can qualify to become a QME if they have completed a residency, whether or not they failed the board certification exam. New QMEs can no longer qualify solely because they had written 625 QME/AME reports from 1990 - 1994 ("grandfathered in").
QME evaluation process
Q. Who completes the panel request form?
Only the injured worker can complete the panel request form and choose the QME specialty. (IMC Reg. 30, 139.2(h), 4061(d), 4062(b))
Q. The injured worker has two different problems from the same injury (for instance a psychiatric and an orthopaedic claim). May he request two panels, one psychiatric and one orthopaedic?
A. For injuries prior to 1/1/94 - The injured worker may have two panels, one for the psychiatric claim and one for the orthopaedic claim.
For injuries on or after 1/1/94- The carrier is only required to pay for one QME evaluation. The injured worker can contact the carrier to tell them about their request and to see if they will authorize payment for both evaluations. If the carrier says they will only pay for only one evaluation, the injured worker will have to choose one specialty. (Labor Code 4061 (d, g) and 4062 (b, c))
Q. The panel of QMEs issued is close to the injured worker's home. However, can give the IW a panel closer to work?
A. The Labor Code requires us to issue panels close to the residence. The IMC can issue a panel of QMEs close to the workplace if both the carrier and the injured worker agree with the request. (Labor Code 139.2 (h), IMC Reg. §31.5 (b)(2))
Q. Can the injured worker get a second panel as two of the QMEs are unavailable for over 60 days?
A. We will send a panel with two new physicians to replace the ones that are unavailable within 60 days. Prior to sending the new panel, we will verify that a physician is unavailable within 60 days. (IMC Reg. §31.5 (a); 33 (c))
Q. The panel QME that the injured workers want to see is unavailable for three months. Can he/she wait for three months to see this QME?
A. Yes. The injured worker has the option to wait to see this QME. (IMC Reg. §33)
Q. The injured worker does not feel any of the physicians listed on the panel will give a fair report. Will the IMC issue a new panel?
A. The panel of physicians is randomly selected by the computer. All the physicians on the panel have applied to the IMC to be a QME and have met all of the requirements to be a QME. Therefore, we are unable to issue a new panel. Only the Workers' Compensation Appeals Board has the ability to determine that a QME is biased or unfair. (139.2(h), 4068, IMC Reg. 50.3)
Q. What happens when a physician on the QME panel is no longer a QME?
A. We will check our records to see if the physician is still an active QME. If he/she is not, we will replace the QME.
Q. Why do the injured workers have to go through the QME process when neither party is objecting to the treating physician's report?
A. For injuries prior to 1/1/94 - Per the Labor Code, the final evaluation to determine permanent disability and future medical care must be performed by a QME. (Labor Code §4061(c))
For injuries on or after 1/1/94 - A QME evaluation is not required if both the carrier and you agree with the primary treating physician's final evaluation and it is a ratable report. (Labor Code §4061(d), §4061.5)
Q. The QME evaluation was yesterday. How long does the QME have to issue the report?
A. This varies depending on the year of injury.
Injuries from 1/1/91 - 12/31/93 - The physician has 45 calendar days, from the date of the commencement of the exam, to issue the report.
For injuries on or after 1/1/94 - The physician 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 in issuing a report:
1. The physician requested medical tests and is awaiting results.
2. The physician requested a consult and is awaiting the consultant's report.
3. "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 are 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 carrier 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 IMC and send a copy to the insurance carrier and to you. This must be filed five days before the report is due. (IMC Reg. §38)
Q. The injured worker needs another evaluation. Should the original QME do another evaluation? What if that physician is no longer performing QME evaluations?
A. The second evaluation should be done by the same QME physician. Two exceptions to this rule are: 1) The physician is no longer a QME. 2) The physician became the treating physician after performing the QME evaluation. If either exception applies, the IMC will replace the QME who performed the evaluation. (Labor Code 4061 (g), 4062 (c))
Complaints regarding QMEs
Q. How should I complain about a QME?
A. Any complaints should either be put in writing and sent to the IMC (attention Legal Unit) or you can make an anonymous complaint by calling our hotline at (800) 999-1041. We prefer that you give us your name and address or phone number so that we can reach you if we have a question.
Q. The QME panel physician did not issue his report and it's been over two months. What recourse is there?
A. First, we will check to see if the QME requested any medical tests or a consult with another physician which would delay the report. If an extension was not requested or if the extension requested was denied, the injured worker has the right to continue to wait for the QME report to be issued. We will issue a new panel if he/she does not wish to wait. In this case, either the carrier or the injured worker should contact the original QME and tell him not to issue his report as his bill will not be paid. (Labor Code 4062.5, IMC Reg. 38, 60 (b) (4))
Q. What do I do if the QME has not responded to a request for a supplemental report?
A. Be advised that a QME has 60 day to complete a supplemental report from the date of a written or electronically transmitted request by a party in the case to the QME. The parties may agree to a 30 day extension or request a replacement panel on the grounds of lateness prior to the date the QME served the report. (DWC-Medical Unit Reg.; 38(h); 31.5(a)(12))