Alexander Sones, MD, QME
If you are involved in a California workers’ compensation claim, you may be scheduled for an evaluation with a Qualified Medical Evaluator, commonly called a QME. But what exactly does a QME do, and what should you expect from the process?
A QME is a physician who has been certified by the California Division of Workers’ Compensation to evaluate medical issues in workers’ compensation cases. Unlike a treating physician, the QME’s primary role is not to provide treatment. Instead, the QME conducts an independent medical evaluation and provides opinions about disputed medical issues in the claim.
The QME process generally involves several important steps.
Before the Evaluation: Reviewing the Medical Records
A QME evaluation often begins well before the injured worker arrives at the physician’s office.
The parties may send the QME medical records and other documents relevant to the claim. Depending on the case, these can include treatment records, diagnostic studies, prior medical records, job descriptions, deposition transcripts, and correspondence from the parties.
The QME reviews these materials to understand the history of the claimed injury, treatment that has already been provided, prior medical conditions, and other information relevant to the questions the physician has been asked to address.
In some cases, the record review can be extensive and may involve hundreds or even thousands of pages.
During the Evaluation: The Examination
The QME then meets with the injured worker for an evaluation. The exact nature of the examination depends on the physician's specialty and the issues involved in the case.
The evaluation will generally include a detailed history of the claimed injury, current symptoms, treatment, work history, prior injuries and medical conditions, and the effect of the condition on the worker’s daily functioning.
The physician will also conduct an examination appropriate to their specialty. An orthopedic QME, for example, may perform a physical examination focusing on strength, range of motion, and the injured body parts. A psychiatric QME may conduct a detailed psychiatric interview and mental status examination anduse psychological testing.
The purpose is to gather the medical information necessary to answer the disputed questions in the workers’ compensation claim.
After the Evaluation: The QME Report
The QME’s work does not end when the examination is over. In many cases, a substantial portion of the physician’s work occurs afterward.
The QME prepares a written medical-legal report explaining the information reviewed, the findings from the evaluation, and the physician’s medical opinions.
Depending on the issues in the case, the QME may be asked to address questions such as:
Whether an injury or condition is work-related
Whether the worker has reached maximum medical improvement
Whether additional medical treatment may be necessary
Whether temporary or permanent work restrictions are appropriate
The degree of permanent impairment
Whether any permanent disability should be apportioned between industrial and non-industrial causes
The QME is expected to explain the medical reasoning supporting their conclusions rather than simply state an opinion.
Once completed, the report is served on the appropriate parties and can become an important piece of medical evidence in the workers’ compensation case.
What Happens if More Information Is Needed?
The initial QME report is not necessarily the end of the process.
After receiving the report, one or both parties may ask the QME to address additional questions or review newly obtained medical records. The physician may then prepare a supplemental report responding to those issues.
In some cases, an attorney may also take the QME’s deposition. During a deposition, the physician answers questions under oath about the evaluation, report, medical opinions, and reasoning behind those opinions.
Supplemental reports and depositions can be particularly important when the medical issues are complicated or when the parties disagree about the meaning or basis of the QME’s conclusions.
The QME’s Role in the Workers’ Compensation System
A QME occupies a different role from a treating physician. The QME is not an advocate for the injured worker, the employer, or the insurance carrier. The physician’s responsibility is to conduct an objective medical evaluation and provide well-supported medical opinions within their area of expertise.
A thorough QME evaluation therefore involves much more than a single appointment. It can include extensive record review, a detailed examination, analysis of complex medical and legal questions, preparation of a comprehensive report, and, when necessary, supplemental reporting or deposition testimony.
Understanding each part of this process can help injured workers and attorneys know what to expect and why the QME’s work can play such an important role in resolving medical disputes in a California workers’ compensation claim.
