A Qualified Medical Evaluator (QME) is a licensed physician certified by a state’s workers’ compensation division to perform independent medical evaluations. QMEs operate within the workers’ compensation system to provide neutral medical opinions when a disagreement arises in a claim. They serve as impartial medical-legal experts, providing a detailed report that helps determine an injured worker’s eligibility for benefits.
The Role of Impartial Medical Evaluation
The primary purpose of the QME is to establish objective medical facts when the treating physician’s findings are disputed by the claims administrator or employer. This evaluation resolves conflicts over the nature, extent, or cause of a work injury. The QME’s report acts as an expert opinion on medical issues that influence the outcome of the case.
One specific function is determining medical causation, which establishes whether the worker’s injury or illness is directly related to their employment. The QME also assesses whether the worker has reached a state of Maximum Medical Improvement (MMI), meaning the condition has stabilized and no further functional recovery is expected. This determination is a prerequisite for evaluating the severity of any lasting physical or mental changes.
The evaluator then uses standardized guides to assign a Permanent Disability (PD) rating, quantifying the degree of residual impairment. The QME provides an opinion on the need for future medical care, detailing any required ongoing treatment. The findings on impairment, MMI, and future care are highly influential in setting the final workers’ compensation benefits.
How a QME Differs from a Treating Doctor
The role of a QME is fundamentally distinct from that of the treating physician who provides ongoing clinical care. A treating doctor’s relationship with the patient is centered on recovery, diagnosis, and management of the injury through active medical intervention. They prescribe medications, order procedures, and focus on the patient’s functional improvement.
The QME does not provide treatment, prescribe medicine, or manage the patient’s recovery trajectory. Their role is purely forensic and evaluative. The QME’s focus is on documenting the injury’s status and providing opinions on legal questions, such as the extent of permanent work restrictions. Their opinion, as an independent medical assessor, carries significant weight in resolving disputes.
The QME Selection Process and Examination
The process for selecting a QME begins when a dispute is formally registered, prompting a request for a panel list from the state’s workers’ compensation administration. The system randomly generates a list of three certified QMEs who specialize in the medical area appropriate for the worker’s injury. These QMEs are typically based locally.
The involved parties, typically the injured worker and the claims administrator, then select one doctor from the panel to perform the evaluation. The doctor prepares by reviewing the worker’s medical records and employment history. During the examination, the QME conducts a physical assessment and interviews the worker about their injury, symptoms, and current functional limitations.
Following the appointment, the QME synthesizes all the information into a medical-legal report. This report includes the diagnosis, causation opinion, impairment rating, and recommendations for future care, and is then submitted to the parties involved. The findings serve as the medical basis for determining final workers’ compensation benefits.