When there is a question as to what workers’ compensation benefits you should be receiving based on your injury, you will be scheduled to see either an Agreed Medical Evaluator (AME) or a Qualified Medical Evaluator (QME) to resolve any medical disputes. Common disputes in a workers’ compensation case that arise are: whether or not your injury was caused by your work, whether or not you need treatment for your injury, whether or not you need to stay home from work to recover, whether your condition is permanent and stationary, and whether you have new and further disability.
There are multiple legal and strategic reasons to consider when choosing whether to use an AME or a QME. Therefore, it is imperative to speak to our highly skilled and experienced workers’ compensation attorneys immediately to discuss your options.
California Labor Code §4062.2(a) states that an AME can only be used if an attorney represents you. If you have an attorney, your attorney and the workers’ compensation claims administrator can come to an agreement on which doctor you will be seen by, without going through the state system used to pick a QME. Once you are seen by the AME, however, you are not then entitled to see a QME. An AME physician may be a QME, but he or she does not have to be one.
Because both sides choose the doctor, the doctor does not represent the claims adjustor nor does the doctor represent the employee. By agreeing to a doctor as an AME the parties are agreeing to be bound by the opinion of that doctor. The doctor determines whether or not there is an impairment or disability and the extent to which the employee is impaired or disabled as a result of a workplace injury. A workers’ compensation judge has the power to reject or modify the AME’s opinion, however, that does not typically happen. Mostly, the workers’ compensation judge will accept the opinion of the AME over the opinion of any other evaluating doctor, including the treating physician.
It is important to understand that the employee, employer, and the workers’ compensation insurance company are bound by the AME’s opinion. If you disagree with the AME, depending on the situation, you may be able to be re-evaluated or your attorney may need to depose the AME. The parties should not agree to an AME unless all are prepared to be bound by the result.
If your attorney and the claims administrator cannot agree on which doctor to use, you must then go through the process of choosing a QME.
A QME is a doctor picked from a list of state-certified physicians issued by the DWC Medical Unit. The QME panel you will choose from is a list of approved physicians that were chosen at random. The physicians on the list must meet educational and licensing requirements to qualify as a QME. They must also pass a test and participate in ongoing education on the workers’ compensation evaluation process.
You will receive a QME panel request form from the claims administrator and are given the first chance to fill out and submit the form. Whoever fills out the form first to request the QME gets to choose the specialty of the doctors on the panel. If you do not submit the form within 10 days, the claims administrator will do it for you and will get to choose the specialty of the QME you will see. (Title 8, California Code of Regulations, section 30, Labor Code sections 139.2(h), 4061(d), 4062(b))
Once you have been seen by the QME, the QME will issue a report within 30 calendar days from the date of the exam. The QME does have the option, under certain circumstances, to request an extension. After you receive the QME report, there are several things that may happen. Among other things, you may disagree with the report, you may disagree with the disability rating, or you may need a further QME. The process can get complicated.
Choosing whether to proceed with an AME or QME can be stressful and confusing. Therefore, it is important to speak to our knowledgeable and skilled workers’ compensation attorneys, as they will help you determine what the best option is for you.
Please contact us today for a FREE 30-minute consultation. Our workers’ compensation attorneys are available to meet with you during business hours, evenings, and weekends. Allegiance Law is located in San Francisco, but we will be happy to drive and meet you. You may contact Allegiance Law, at 415-404-6395. Or you may contact us by filling out the client inquiry form on this page.