A Qualified Medical Evaluator (QME) is a physician certified by the California Division of Workers’ Compensation (DWC) Medical Unit to perform independent medical-legal evaluations. This process is specific to the California Workers’ Compensation system and is initiated when a disagreement arises about the medical aspects of an injured worker’s claim. The QME provides an impartial, expert opinion intended to resolve conflicts between the injured worker, the employer, or the insurance company. This evaluation helps determine the proper benefits, necessary treatment, and the extent of the work injury.
The Role of the Qualified Medical Evaluator
The QME acts as an impartial medical expert rather than a treating physician. These doctors, who can include medical doctors, chiropractors, or psychologists, must pass an examination and receive specialized training in workers’ compensation regulations and report writing. They operate under the guidelines established in the California Labor Code.
The need for a QME typically arises when the injured worker, the employer, or the claims administrator disputes the findings of the primary treating physician (PTP). Common points of contention involve whether the injury is truly work-related, the extent of necessary medical treatment, or the worker’s ability to return to their job.
The QME’s primary function is to assess the medical evidence and the worker’s condition to determine several key factors. This includes establishing the causation of the injury and evaluating when the worker has reached Maximum Medical Improvement (MMI). MMI is the point at which the condition has stabilized and is not expected to improve with further medical care.
Unlike the PTP, who focuses on ongoing patient care, the QME focuses strictly on the legal and medical-legal questions of the claim. Their independent assessment helps to move the claim toward resolution.
Preparing For and Undergoing the Examination
The process of selecting a QME begins when a dispute is formally declared, prompting the DWC to issue a panel of three potential QMEs. The injured worker or their representative then has ten days to select one doctor from this panel, or the choice defaults to the claims administrator. The chosen QME must specialize in a medical field appropriate to the worker’s injury, such as orthopedics or psychology.
Preparation for the examination ensures an accurate evaluation. Before the appointment, the QME reviews all relevant medical records, including reports from the treating physician, diagnostic test results, and prior correspondence. The worker should review their medical history and symptoms to be prepared to discuss their condition thoroughly.
During the appointment, the QME will first take a detailed history of the injury, symptoms, and how the condition impacts daily life and work duties. The worker should be specific and consistent about their pain levels and functional limitations, as the QME’s report relies heavily on the credibility of the history provided. It is important to mention all affected body parts and limitations.
Following the detailed history, the QME will perform a physical examination tailored to the reported injuries. This hands-on assessment involves testing range of motion, muscle strength, reflexes, and sensation, measured according to standardized medical protocols. The QME will not offer treatment, prescriptions, or referrals, as their role is purely evaluative, not therapeutic.
After the in-person examination, the QME has a set timeframe, typically 30 days, to prepare and serve the comprehensive medical-legal report to all parties involved. This deadline can be extended if the QME determines that additional diagnostic testing is necessary to finalize their medical opinion.
Understanding the QME Report and Claim Finalization
The QME report serves as the primary medical evidence that dictates the trajectory of the workers’ compensation claim. The document provides definitive medical answers to the disputed questions. Each report must contain a clear diagnosis based on the physical examination and a review of the medical records.
A significant component of the report is the determination of causation, addressing which parts of the injury are directly attributable to the work event. The QME must also make recommendations regarding future medical care, including what treatments, surgeries, or ongoing prescriptions may be required for the work injury. These recommendations establish the worker’s entitlement to future medical benefits.
The most substantial finding in the report is the Permanent Disability Rating (PDR), which quantifies the worker’s lasting physical or mental impairment. To calculate this, the QME uses the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition, which assigns a Whole Person Impairment (WPI) percentage. This WPI measures the loss of function of the body as a whole.
The WPI percentage is then adjusted based on the worker’s occupation and age at the time of the injury to arrive at the final PDR. This final percentage is the metric used to determine the amount and duration of the Permanent Disability benefits the worker will receive. The QME report’s conclusions are heavily relied upon to finalize the claim through a settlement or award.