The QME process

What is a QME in California workers’ comp?

A QME, or Qualified Medical Evaluator, is a physician certified by the Medical Unit of the Division of Workers’ Compensation. The QME evaluates injured workers when a medical question is in dispute. The process exists because the treating doctor and the insurer often disagree, and someone outside the treatment relationship has to decide.

A QME does not treat you. The QME examines you once, sometimes again later, reviews your medical records, and writes a medical-legal report. That report answers specific questions the parties raise, and a workers’ compensation judge relies on it heavily.

QMEs come from many specialties, including orthopedics, psychology, internal medicine, neurology, and chiropractic. The specialty requested for the panel should match the injury in dispute.

When is a medical-legal evaluation needed?

You need a QME evaluation when you or the insurer disputes a medical issue that decides benefits. Labor Code §§ 4060 through 4062.2 set out which disputes go to a QME and how the parties choose the evaluator.

• Whether the injury is work-related Under § 4060, when the insurer denies the claim, a QME or AME evaluates causation.
• Disputes over the treating physician’s findings Under §§ 4061 and 4062, either side can object to the primary treating physician’s conclusions. The objection can cover disability, work restrictions, permanent and stationary status or future medical care.
• Permanent disability The QME measures lasting impairment, which the rating schedule then converts into a permanent disability rating.
• Apportionment The QME addresses how much of the disability work caused and how much other factors caused, under Labor Code § 4663.

Disputes over whether a specific treatment is medically necessary usually go through utilization review and independent medical review, not a QME. The two processes run separately.

How is a QME panel assigned?

A QME panel is a list of three evaluators in the requested specialty. The Division of Workers’ Compensation Medical Unit assigns them at random after one side requests a panel. How the parties choose the final evaluator depends on whether you have an attorney.

• Without an attorney (§ 4062.1) You choose one of the three physicians on the panel. You then schedule the QME appointment within the deadline stated in the panel paperwork.
• With an attorney (§ 4062.2) Each side strikes one name from the panel within 10 days of its assignment. The physician who remains becomes the QME.
• By agreement When you have an attorney, both sides can skip the panel and agree on an Agreed Medical Evaluator instead.

The requested specialty matters as much as the individual doctor. A panel in the wrong specialty can produce a report that misses the actual injury, and changing course later takes time.

Should the case use a QME or an AME?

A QME comes from a state-assigned panel, while an Agreed Medical Evaluator (AME) is a physician both sides choose together. An AME is only available when the injured worker has an attorney. Whether to use one is a judgment call that depends on the injury and the doctors available.

An attorney can tell you whether an AME is realistic in your case and which physicians the insurer is likely to accept.

What happens at a QME evaluation?

At a QME evaluation, the physician takes a detailed history, performs a physical or psychological examination, and reviews your medical records. The appointment often takes longer than a normal doctor’s visit, and you may complete questionnaires first.

1. History The QME asks how the injury happened, your job duties, your symptoms, earlier injuries and your treatment so far.
2. Examination Range of motion, strength, reflexes and other measurements, or testing for a psychiatric claim.
3. Record review The QME reviews records served by both sides under the rules for what may be sent.
4. Report The QME issues a written report addressing causation, temporary disability, permanent and stationary status, impairment, apportionment and future medical care as needed.

The QME measures permanent impairment using the AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition. California uses those Guides for injuries on or after 2005. The state’s rating schedule then converts the impairment into a permanent disability rating.

How can you prepare for a QME appointment?

Good preparation for a QME appointment means an accurate, complete and consistent account of your injury and symptoms. The QME compares what you say with your records, so accuracy counts for more than detail.

• Write down your symptoms Which activities are harder now, which positions hurt, and how your sleep and daily life have changed.
• Remember earlier injuries Mention them. Leaving out a prior injury that appears in the records undermines everything else you say.
• Neither minimize nor exaggerate Describe your good days and your bad days. QMEs learn in training to look for inconsistency in both directions.
• Ask for an interpreter If English is not your first language, you are entitled to a certified interpreter at the evaluation. Ask in advance.

Labor Code § 4062.3 prohibits informal contact with the evaluator by either side. Anything the QME considers has to come through the permitted channels, which protects you as much as it restricts you.

How long does the process take?

The QME process usually takes several months from the panel request to the final report, though the range is wide. The timing depends on the specialty, the evaluator’s calendar and how many records need review.

Some specialties have long waits for a first appointment. After the exam, the report often follows within weeks, but the QME may ask for additional testing or records first. Supplemental reports and depositions add more time.

Scheduling rules and evaluator availability change. An attorney can give you a realistic range for your specialty and your facts, including the slow version.

Temporary disability and treatment do not stop because a QME evaluation is pending. The insurer continues paying accepted benefits while the parties resolve the medical dispute.

What happens after the QME report?

After the QME report, the parties use it to settle the disputed issue or request a rating. Otherwise, they prepare for a hearing before a workers’ compensation judge. Most cases move toward resolution once a solid report is in.

If the report has gaps or errors, either side can ask the QME for a supplemental report or take the QME’s deposition. A judge relies only on reports that are substantial medical evidence: reasoned, based on an accurate history, and addressing the right legal questions.

Once the medical picture is clear, the case usually turns to how it ends. The page on workers’ comp settlements explains Stipulations with Request for Award and Compromise and Release. If the dispute is about whether workers’ compensation covers the claim at all, see denied claims. And if you have not yet reported the injury, start with filing a workers’ comp claim.

What does the evaluation cost you?

The insurer pays the QME’s or AME’s fees for the evaluation and report, so the medical-legal process itself costs you nothing. With this firm, the attorney’s fee in a workers’ compensation case is typically around 15% of the award. A workers’ compensation judge approves it under Labor Code § 4906, and it is paid from the award, with nothing up front. The fees and consultations page and the workers’ compensation overview explain more.

Your first consultation is free and takes about thirty minutes, in person in Glendale, by phone or by video.