Answers to frequently asked questions about qualified medical evaluators (QMEs) for physicians
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.
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 issues QME panels to injured workers and claims administrators, 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 unit also investigates complaints against currently certified QMEs that allege billing violations and violations of guidelines contained in the Labor Code, the regulations, and other laws concerning a QME’s conduct of an evaluation and/or preparation or submission of a report.
You may reach the Medical Unit by calling 510-286-3700 or 1-800-794-6900.
Q. What are the Labor Code sections and regulations that apply to QMEs?
A. Labor Code section 139.2 sets forth the law regarding appointment, qualification, termination, guidelines, procedures and admissibility of medical evaluations and submission of reports. Labor Code sections 4628, 4060, 4062.1 and 4062.2 set forth evaluation and reporting requirements. The QME regulations are found at California Code of Regulations, title 8, sections 1 through 159. The medical-legal fee schedule is found at sections 9793 through 9795.
Q. Do the new standardized paper billing form regulations that take effect Oct.15, 2011 apply to QMEs?
A. No, the new regulations that are effective Oct. 15, 2011 for submission of bills to carriers for services render applies to providers billing for treatment using the Official Medical Fee Schedule, not the Medical-Legal Fee Schedule.
Q. How long does the exam take and where are the exams being given?
A. Time: You have three hours to complete the exam. Please arrive 30 minutes prior to your scheduled appointment time to complete the necessary sign-in process.
Location: The exam is administered by CPS HR Consulting’s partner, Pearson VUE. Candidates can take the exam at one of Pearson VUE’s several convenient test centers.
Q. If I fail, can I appeal my exam score?
A. You may appeal the failing grade by writing your specific concerns to the administrative director. Appeals will be considered on a case by case basis. Appeals will be accepted immediately after a candidate has completed the exam and until 10 days after the date of the exam results letter. You must be prepared to document the reasons for your appeal. (8 CCR § 11(f)(10))
Grounds for appeal are:
- Significant procedural error in the exam process
- Unfair Discrimination
- Bias or fraud.
Q. What is the annual fee to be a QME?
A. The annual fee is $250 if you performed 25 or more comprehensive medical-legal evaluations in the year prior to assessment of the fee. If you performed 11-24 examinations, the annual fee is $125. If you performed 0-10, the fee is $110. This fee is for one office location. If you wish to have additional locations, the fee is $100 for each additional location. (Labor Code § 139.2 (n), 8 CCR § 17)
Q. Is there a way you can check to see how many panels my name appeared on in the last 12 months?
A. Yes. Call the DWC Medical Unit at (800) 794-6900 and someone will assist you.
Q. How many years is my QME status valid?
A. QMEs who initially applied prior to July 17, 1993 were approved for a four-year term. QMEs who were approved on or after July 17, 1993, were approved for a two-year term. Once a QMEs initial term expires, he/she will be reappointed every two years. A QME must pay an annual fee in order to maintain his/her status and show proof of having attended 12 hours of combined education in 24 months. . For initial reappointment, the Medical Unit uses the QME exam passed as 6 hours of continuing education. The QME is only required to receive 6 hours of continuing education, in order to fulfill the 12 hour requirement.
Q. How can I add another office location?
A. Write us a letter requesting that we add the new office location. Please include the street address, phone number and e-mail address. There is a $100 fee for each additional office. We encourage QMEs to add all new offices when they pay their annual fee assessment. If you wish to add a new location at any other time, you may do so; however, you will be billed again for that location when you pay your annual fee. (8 CCR § 17(b))
Q. How can I replace one office or how can I close one office?
A. Put the request in writing to the DWC Medical Unit. We will make the change when we get your letter. Be sure and include the date you wish the office closed along with the physician’s signature.
Q. I was recently approved to do QME evaluations and I would like information on how to proceed. Could you give me advice?
A. The staff at the DWC Medical Unit unit will be happy to assist you if you have specific questions. If you do not have a copy of the QME regulations, you can download them from the DWC Web site.
Q. To whom do I send copies of the QME or AME report?
|Action||Unrepresented QME Labor Code § 4060||Represented QME Labor Code § 4060||Unrepresented QME Labor Code § 4061||Represented QME Labor Code § 4061||Unrepresented QME Labor Code § 4062||Represented QME Labor Code § 4062|
|Who gets served ?||Applicant||Applicant and Applicant's attorney||Applicant||Applicant and Applicant's attorney||Applicant||Applicant and Applicant's attorney|
|Claims Administrator or the defense attorney||Claims Administrator or the defense attorney||Claims Administrator or the defense attorney||Claims Administrator or the defense attorney||Claims Administrator or the defense attorney||Claims Administrator or the defense attorney|
|Is DEU served?||No||No||Yes||No||No||No|
|What is served?||Medical Report||Medical Report||Doument Coversheet||Medical Report||Medical Report||Medical Report|
|QME Form 111-QME Findings Summary Form||QME Form 122-AME or QME Declaration of Service of Medical-Legal Report Form||Doucment Seprator sheet-DWC-CA form 10232.2||QME Form 122-AME or QME Declaration of Service of Medical-Legal Report Form||QME Form 111-QME Findings Summary Form||QME Form 122-AME or QME Declaration of Service of Medical-Legal Report Form|
|Doucment Seprator sheet-DWC-CA form 10232.2|
|QME Form 111-QME Findings Summary Form|
|Doucment Seprator sheet-DWC-CA form 10232.2|
|DWC-AD Form 100-Employee's Disability Questionnaire|
|Doucment Seprator sheet-DWC-CA form 10232.2|
|DWC-AD Form 101-Request for Summary Rating Determination of Qualified Medical Evaluator's Report|
Q. How many days do I have to complete the QME report?
A. The QME must prepare and submit an initial or follow-up comprehensive medical-legal evaluation within 30 days from the date the QME has seen the employee. (8 CCR § 38)
Q. Who sets up the interpreter service at a QME evaluation?
A. Interpreter service must be from a state certified interpreter. The QME should note in the appointment notification form that a certified interpreter is required. When making the appointment, your staff should ask the injured worker which language is needed. The claims adjuster will make the necessary arrangements and also pay the interpreter. (Labor Code § 9795.3, 8 CCR § 34(c))
Q. What are the grounds for granting an extension on completing the med-legal report?
A. You must complete the QME form 112 (QME/AME Time Frame Extension Request) and send the original to the DWC Medical Unit with copies to the injured worker and the insurance carrier five days before the report is due to be served on the parties. The valid reasons for an extension are : 1) you requested that the injured worker have medical tests and you are waiting for the results 2) you requested a consult and are waiting for the consultant's report 3) good cause (medical emergency for you or your family, death in your 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.
You may not request an extension because the carrier failed to provide the injured worker's medical records or previous medical tests. (Labor Code § 139.2(l)(A), 8 CCR § 38)
Q. How long of an extension will I be able to obtain for issuing the QME report?
A. If the extension is being requested due to good cause as defined above, you may receive a maximum extension of 15 days. If the extension is being requested because you are writing for test results or a consult report, then you may receive a maximum extension of 30 days.
Q. What is the time frame for supplemental reports?
A. You have 60 days from the date of the written request for a supplemental report. The time frame may be extended up to 30 additional days if the parties agree without the need to request an extension from the medical director. (8 CCR § 38(h))
Q. With whom may I consult if more medical information is required?
A. You may only consult physicians who have treated the injured worker for this injury. ( 8 CCR § 35(i) and (j))
Q. What is the purpose of sending the medical and non-medical records to the QME?
A. These records give the QME a history of the injury. The treatment records document the problems that the injured worker is having from the injury. Test results such as MRIs are forwarded so that the QME will not have to duplicate the tests. Medical records on 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 a letter from the carrier, are sent to provide information regarding the injury to the QME doctor.
Q. What do I do if I am going to be unavailable for panel assignment?
A. If you will be unavailable to schedule or perform comprehensive medical evaluations for 14 days (up to a maximum of 90 days during a one year fee period), fill out QME form 109 and submit it to the DWC Medical Unit at least 30 days prior to the date of unavailability. (8 CCR § 33)
Q. What do I do if I have a conflict of interest?
A. A QME who knows, or should know, that he or she has a disqualifying conflict of interest (see 8 CCR § 41.5) with any person or entity listed in subdivision 41.5(c), that also is involved in the case the evaluator is handling, must notify the parties in writing of the conflict of interest using QME form 123. A QME may disqualify himself or herself also for conflict of interest whenever the evaluator has a relationship with a person or entity in the case that causes the evaluator to decide it would be unethical to perform a comprehensive medical-legal evaluation in the case. (8 CCR § 41.5(e) The parties in a represented case may waive a QME’s conflict of interest by complying with the written documentation as stated in. (8 CCR § 41.6 (c)(3).
Q. What are a QME’s responsibilities in preparing a QME Appointment Notification Form (Form 110)?
A. Whenever a QME makes an appointment for a comprehensive medical-legal evaluation, the QME must complete a QME Appointment Notification Form (Form 110). No Form 110 is acceptable if it contains formatting or any language that is in addition to or different from that stated in the version published on the DIR Web site and no exceptions to this policy will apply. To “complete” the form, the QME must ensure that all of the blanks are filled out with complete and accurate information received from the party requesting the appointment.
“Location of appointment” must include the complete address listed for the QME on the panel from which the QME has been selected. The appointment may not be scheduled for any other location unless the injured worker has first agreed in writing to be evaluated at a different location, at which the QME must be currently certified.
The selected QME’s name must be entered on two lines, with: (1) a signature entered when the QME is satisfied that the form has been filled out with complete and accurate information, and (2) the QME’s name printed or typed immediately below the signature.
If the QME determines that a consultation is necessary, and the consulting physician is not selected by the parties from a QME panel issued by the Medical Unit, the referring QME must arrange the consultation appointment and advise the injured employee and the claims administrator, or if none the employer, using Form 110. For clarity, it is appropriate to indicate the consulting physician’s name on the same line as “location of appointment.”
The completed Form 110 must be postmarked or sent by facsimile to the employee and the claims administrator, or if none the employer, within five business days of the date the appointment was made. In a represented case, a copy of the completed form shall also be sent to the attorney who represents each party, if known.