QMEs and AMEs in California

If you’ve been injured while on the job, and have filed a workers’ compensation claim, it is possible that you may need to be examined by either a Qualified Medical Evaluator (QME) or an Agreed Medical Evaluator (AME) to address any disputes that might arise such as your temporary disability status, whether you have reached a permanent and stationary (P&S)/maximum medical improvement status(MMI), permanent impairment/disability issues, future medical treatment needs or whether you can return to your usual and customary employment to name a few.  This QME or AME situation usually occurs only when there are disagreements between you and/or the insurance company over the treating physician’s opinions on the issues involved.

The insurance company claims administrator or you may disagree with what your physician thinks from a medical standpoint about the nature and extent of your injuries, impairment/disability related to your injuries and/or their opinions on other issues including the need for future medical treatment to cure or relieve the effects of your industrial injuries. When this happens, an entirely different doctor – AME or QME –  may become involved in the case to address these disagreements. The disputes may include, but are not limited to the following:

  • Whether your injury was caused by the work you do;
  • Whether the injury requires treatment;
  • Whether you should stay off work while you recover from your injuries;
  • Whether your condition is permanent;
  • Whether you have a new and further disability;
  • The permanent disability rating that is given.

QME and AME Differences

A QME is a physician who is licensed to practice in California and can include medical doctors, chiropractors, dentists, osteopaths, podiatrists, acupuncturists, and optometrists. A QME must be certified by the Division of Workers’ Compensation Medical Unit in order to perform the medical and legal patient evaluations, and must meet additional educational and licensing requirements.  They must also pass a test and participate in ongoing education involving the workers’ compensation evaluation process.  If you are unrepresented in your workers’ compensation case and a dispute arises, then you may be evaluated by a Panel Qualified Medical Evaluator to address the dispute.    

On the other hand, an Agreed Medical Evaluator (AME) is a physician who is selected and agreed upon by both the defense and the injured worker’s attorney to complete the medical and legal patient evaluations. An AME is only utilized if the injured worker is represented by an attorney.

If your attorney and the claims administrator for your employer’s insurance company (or their attorney) agree upon a physician as an AME, then the parties will generally  not have to use the state system for finding a QME, unless another specialty evaluation is needed and the parties cannot agree on another AME in that specialty. If the parties cannot come to an agreement on the use of an AME, then they will need to ask for a Panel QME.

It is clearly in your best interest to have a qualified, experienced attorney representing you in your workers’ compensation case, because as you can see, these types of situations can get complicated quickly. Attorney Todd Tatro has been focused solely on workers’ compensation law for several years and has over 30 years of experience in representing the Valley’s injured workers.  He is a Certified Specialist who handles these types of cases and can offer you clear guidance to see your workers’ compensation claim to a successful conclusion.

Requesting a QME

The QME examination can be requested by you, your attorney, or the insurance company’s claims administrator or their attorney .  Once requested, a panel of three QMEs will be provided to the requester by the Department of Workers’ Compensation Medical Unit. Each QME panel request is randomly generated, and each physician on the panel will be a specialist in the area of medicine you request. When the Panel QME list is received, there are strict time frames within which to select a QME from the panel and set an appointment for the QME with the selected physician and advise the claims administrator.  If you do not act within the required time frames, the claims administrator will usually select the physician they want off the panel (which will usually be the one least favorable to you and most favorable to them)  and set the appointment.  When the QME from the panel is chosen, they will examine you and prepare a report on your condition and addressing the issues involved. Any further disputes will usually need to go directly to that QME to be addressed.

Obtaining a Panel List

If you are not legally represented by an attorney, you can request a panel yourself through the DWC Medical Unit. But be aware that while the request itself is simple, choosing the correct physician for your case from the panel is a decision best left to an attorney who will already be familiar with the panel physicians or be in a better position to try and select the most favorable physician on the list to act as the QME. Currently, there are 42 different types of medical examiners that the DWC recognizes, and that includes 11 different types of internal medicine specialists. Choosing the right one – and your case may depend on it – is a harrowing experience when you don’t have anyone legally representing you. Furthermore, there are specific types of doctors that are skilled with the more complex claims that involve cumulative injuries or pre-existing injuries. So while you can choose a physician on your own, you’re taking a huge risk by doing so. If you do choose the wrong doctor, your case could be delayed, or you could end up with little or no compensation at all for your industrial injuries.  Once the panel list request has been submitted to the DWC, you should receive a list of three QME’s to choose from within 20 working days or 30 calendar days. When you receive the panel list, you have ten days to choose your doctor, and make your appointment with that doctor. At this point, you will be required to contact the claims representative from the insurance company to let them know the physician you have chosen and the date of your appointment.

Disagreeing with the QME

If you don’t agree with what the QME has to say about your injury or prognosis, you may be able to request a supplemental report or maybe negotiate a compromise with the claims administrator or their attorney.  However, this is usually best left to an experienced workers’ compensation attorney. You have 30 days from the date of the receipt of the report to address the issue.

If you don’t have an attorney and want to challenge the QME report, contact the insurance company’s claims administrator. If you still can’t get anywhere, contact your local Workers’ Comp Appeals Board district office, where an Information and Assistance officer will try to help.

If you belong to a union, contact your mediator or ombudsperson to seek out help.

Or, simply contact a qualified workers’ compensation  attorney like Todd Tatro and let him assist you with the burden of the entire process. Mr. Tatro’s law practice focuses entirely on representing injured workers in their workers’ compensation claims, so you know he’s an authority and experienced. In fact, he is a Certified Worker’s Compensation Specialist. All he does is workers’ compensation – not personal injury, not medical malpractice, not divorces or bankruptcies.

Put your future in the hands of one of the absolute best. Your workers’ compensation claim is far too important to be put into just any attorney’s hands.  You need someone like Mr. Tatro with to help guide you through this complex system in order to try and protect your rights and interests.  Contact Mr. Tatro’s office at (559) 431-0123 or through his online contact page.