What is a Qualified Medical Evaluator (QME), and how do I prepare?

A Qualified Medical Evaluator, or QME, is a doctor the state certifies to settle medical arguments in a workers' comp case: whether work caused it, how bad it is, whether it's permanent. You'll get a panel of three names, and most of the windows to act on that panel are 10 days. Don't let the letter sit.

What the QME actually decides

The QME isn't your doctor and won't treat you. They examine you once (sometimes more), read your records, and answer the questions the two sides are fighting about. Was this caused by your job? Can you work, and with what limits? Have you stopped improving? How much permanent disability do you have, and is any of it from something else? Will you need care down the road?

Judges give these reports a lot of weight. That's why the choice of doctor matters and why showing up prepared matters. Your employer or its insurer pays for the evaluation, not you (Labor Code section 4064).

Sources: DWC Injured Worker Guidebook, Chapter 4; Labor Code § 4064; DWC Medical Unit.

Is this even a QME problem?

California sends different medical fights down different roads, and taking the wrong one burns time. If the argument is over whether a specific treatment your doctor asked for is necessary, that's independent medical review, and you have 30 days from the utilization review decision to ask for it. The medical treatment guide covers that road. Everything else in the legal case (cause, work restrictions, permanent and stationary, your disability level, future care) goes to a QME, or to an AME if you have a lawyer and both sides agree on one.

Your letter should say which process it's using and what the deadline is. Read it twice.

Sources: DWC Guidebook, Chapter 3; Labor Code § 4610.5.

The panel, and the 10-day windows

How it works depends on whether you have a lawyer. With one, either side can ask the DWC Medical Unit for a panel of three QMEs, no sooner than 10 days after the objection. Each side then strikes one name within 10 days, and the doctor left standing is your QME. Your lawyer books the exam within 10 days. Represented workers also have a second option: both sides can agree on an Agreed Medical Evaluator. An AME doesn't need state QME certification, and because both sides picked them, it's harder for either side to cry bias later.

Without a lawyer, you have 10 days to send in the panel request form. Once the three names arrive, you have 10 days to choose one and make the appointment. Miss it and the claims administrator can pick for you.

QME and AME key deadlines

Step	With a lawyer	Without a lawyer
Request the panel	No earlier than 10 days after the objection	Submit the request form within 10 days
Narrow the panel	Each side strikes one of three names within 10 days	You choose one of the three within 10 days
Book the exam	Your attorney arranges it within 10 days	You book it within the same 10 days
Other option	Both sides may agree on an AME	Not available
Who pays	The employer or its insurer

Before you choose or strike anyone, look each doctor up: specialty, location, and whether they speak your language. Questions about the panel itself go to the DWC Medical Unit at 1-800-794-6900.

Sources: Labor Code § 4062.2; DWC Injured Worker Guidebook, Chapter 4.

You can reach our office at (323) 656-9040.

Walking into the exam

Most of what goes wrong at a QME exam is avoidable. Before you go:

• Write your story down. How you got hurt, when it started, every doctor you've seen. Bring the list of medications and any brace you wear.
• Be straight about old injuries. The doctor will probably see those records anyway. Leaving one out looks worse than the injury itself.
• Talk about real life. What you can't lift, how long you can sit, whether you sleep, whether you can pick up your kid. Good days and bad days, without stretching either.
• Need an interpreter? Say so to your lawyer or the claims administrator well before the date.

Keep conversation with the office staff to scheduling. Afterward, in the parking lot, jot down how long the doctor actually spent with you and what tests they did. You'll be glad you did if the report doesn't match.

When the report comes back

Both sides get a copy. If it's unclear, incomplete or built on wrong facts, there are ways to respond, each with its own deadline, and a lawyer can tell you which fits. The report then feeds straight into your permanent disability rating or the fight over a denied claim. This is the stage where a lot of people decide to bring in a lawyer, and earlier is better than later.

Two quick ones

Source: DWC Injured Worker Guidebook, Chapter 11.