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QUALIFIED MEDICAL EVALUATOR (QME)

The Qualified Medical Evaluator system was created by the legislature in 1989 and has undergone a number of revisions, including major changes in 2013 limiting discussion of medical treatment to future medical care.

There must be a dispute about compensability, disability, or future medical care before the QME process can begin. SB 863 changed what a QME can discuss. A QME can no longer discuss medical necessity, but still gives opinions on injury AOE-COE, parts of body injured, factors of permanent disability, apportionment, and need for future medical treatment.

The QME must conduct the examination; a nurse may perform "those functions routinely performed by a nurse, such as taking blood pressure." Labor Code §4628. "That section 4628, subdivisions (a) through (e) is a strict liability statute is obvious from its plain language, at least insofar as the admissibility of a medical-legal report is concerned....Section 4628 was enacted in 1989 as part of the overall reform package to ensure the reliability of the medical evaluation, which it hoped to achieve by controlling the quality of the medical-legal report. The Legislature referred to section 4628 as an anti-ghostwriting statute." Scheffield Medical Group v. WCAB (1999) 70 Cal. App. 4th 868.

Labor Code §4062.2:  "If the employee is represented by an attorney, a medical evaluation to determine the disputed medical issue shall be obtained as provided in Section 4062.2, and no other medical evaluation shall be obtained. If the employee is not represented by an attorney, the employer shall immediately provide the employee with a form prescribed by the medical director with which to request assignment of a panel of three qualified medical evaluators, the evaluation shall be obtained as provided in Section 4062.1, and no other medical evaluation shall be obtained."

The DWC favors unrepresented workers, yet the unrepresented worker knows nothing about the bias of the QMEs, so the process is faster for the unrepresented worker but fraught with danger when selecting names or trying to improve on the doctor's report. Labor Code §139.2(h)(1): "When requested by an employee or employer pursuant to Section 4062.1, the medical director appointed pursuant to Section 122 shall assign three-member panels of qualified medical evaluators within five working days after receiving a request for a panel. Preference in assigning panels shall be given to cases in which the employee is not represented. If a panel is not assigned within 20 working days, the employee shall have the right to obtain a medical evaluation from any qualified medical evaluator of his or her choice within a reasonable geographic area. The medical director shall use a random selection method for assigning panels of qualified medical evaluators. The medical director shall select evaluators who are specialists of the type requested by the employee. The medical director shall advise the employee that he or she should consult with his or her treating physician prior to deciding which type of specialist to request."

Represented workers are treated to a more complex form and long delays in obtaining a panel, a strike procedure where each side strikes one name and the third, if available, becomes the QME. 

SB 863 revised Labor Code §139.2(h)(3)(B): An evaluator shall not conduct qualified medical evaluations at more than 10 locations.

 

Label Item Links Comments
Labor Code Appointment of QMEs 

Disputes over the compensability of any injury can be decided by QME

QME restricted to determining permanent disability and future medical care

Issues other than compensability of injury, permanent disability, future medical care -- what is left?
LC §139.2

LC §4060


LC §4061


LC §4062
 

See AOE-COE and Causation


Under SB 863, current medical treatment disputes would no longer be subject to resolution by AMEs or QMEs. Starting January 1, 2013, and phasing in completely for all dates of injury after July 1, 2013, if a medical treatment dispute results in the delay, denial or modification of treatment recommended by the injured worker’s treating physician, the only method of resolution available to employee after utilization review would be an Independent Medical Review (IMR) conducted pursuant to the procedures set forth in Labor Code §4610.5.
Regulations/Rules Qualified Medical Evaluator regs

New Regs effective 9/1/15

Exchange of information: Rule 35

Evaluation Procedures

Ethical Requirements for QMEs, one of which is "Communicate with the injured worker in a respectful, courteous and professional manner."

Areas of Expertise & Scope of Practice

QME Regs

Current regs

8 CCR §35

Evaluation regs

Ethical requirements

Areas of Expertise/Scope of Practice

 
Cases  Tsegay Messele v. Pitco Foods, Inc. (2011) 6 Cal. Comp.Cases 1187

"The Legislature referred to section 4628 as an anti-ghostwriting statute." Scheffield Medical Group v. WCAB (1999) 70 Cal. App. 4th 868
Messele v. Pitco Foods, Inc.

Scheffield Medical Group v. WCAB
 
Forms All QME forms

Unrepresented worker: Panel Request (Form 105)



Request for Factual Correction of an Unrepresented Panel QME Report

Represented worker: Panel Request is now online for initial requests


Replacement panel request: QME regulation 31.5


Additional panel request: QME regulation 31.7

QME Complaint form
QME forms

Panel Request (Form 105)

Request correction


Online process


Replacement Panel Request


Additional Panel Request


QME Complaint 
 


















Websites DWC QME process

Look up a QME by name, specialty, geography.

General information on the Discipline Unit

Disciplined QMEs
QME process

QME Database

QME Discipline Unit

Disciplined QMEs List

 





Read this carefully. There are old entries with expired dates.
Practice Tips   The rules are a booby trap for the unwary, so know and follow them. See QME Regs 

Also, note that the new QME request form for unrepresented workers (105) has a missing entry on page 3. The new form lists the gastroenterology code (MMG) but is missing “-Gastroenterology.” MMG has “Internal Medicine” next to it and also next to MMM. The code is there for gastroenterology (MMG) but not the label.

See DWC handout from DWC 21st annual educational conference 2/14: DWC Med Unit tips, etc.

 
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