California Workers’ Comp QMEs: Frequently Asked Questions (FAQS)

As explained by the California Department of Industrial Relations (DIR), QMEs are licensed doctors who have been trained and certified by the state’s DWC. When there are questions regarding the nature and severity of an employee’s injury, a Qualified Medical Evaluator (QME) may be brought into to bring additional clarity and help resolve the issue. Here, our Fresno workers’ comp defense lawyers answer four frequently asked questions about QMEs in California

Is a QME Required in Every Case?

No. The basic purpose of the QME process is to provide the parties with access to a neutral medical evaluator. If there is a dispute, a QME will provide an additional assessment that, ideally, offers additional information to help resolve the dispute. Both parties—the worker and the administrator/insurer—have the right to request a Qualified Medical Evaluator. If there is no disagreement regarding the medical assessment, then a QME is not necessary. Further, some disputes cannot be effectively resolved through the QME process. 

Are There Any Downsides to Requesting a QME?

Yes. In California, the workerscompensation claims administrator pays for the QME. From the perspective of the employer/insurer, there is a downside to requesting (and paying for) a QME that will only produce additional negative evidence. Beyond that, a QME may not be advisable if the report will not address the material issues that are in dispute. For example, a dispute over the reasonableness of past treatment is not an issue on which a QME will comment. Instead, that matter is better addressed through an alternative process called an Independent Medical Review (IMR). 

How Should an Administrator/Insurer Prepare for a QME?

A Qualified Medical Evaluator should receive a case file with relevant information before the examination begins. Insurance companies should generally send over a list of questions that they qnat answered by the QME. These questions should be narrowly tailored to suit the specific circumstances of the case. Questions can be useful for both fact-finding purposes and for building a workers’ comp defense. 

What Happens if We Disagree With the Evalutor’s Assessment?Ultimately, the Qualified Medical Evaluator does not make a final decision on any issue. Instead, the doctor will issue an independent medical assessment that, in most cases, includes a disability rating for the claimant. If an insurer disagrees with the assessment of the QME, they can still raise a defense. However, it is important to emphasize that a QME’s report will carry significant weight should the workers’ comp claim go before a judge.