In the realm of workers’ compensation in California, Agreed Medical Evaluators (AMEs) and Qualified Medical Evaluators (QMEs) play a crucial role in evaluating the injuries of workers where liability/compensation is in question. These evaluations are pivotal in resolving disputes and determining compensation. A comprehensive overview of AMEs and QMEs highlights how Spectrum Evaluators supports Physicians and offers practical guidance for physicians involved in workers’ compensation cases is detailed as under:
- Introduction
For a physician navigating the workers’ compensation system in California, distinguishing between AMEs and QMEs is essential. This article targets California physicians who may be involved in or are considering becoming involved in workers’ compensation evaluations. Additionally, Spectrum Evaluators offer valuable resources and support for QMEs, helping to streamline their practice and enhance their effectiveness. |
2. What is an AME (Agreed Medical Evaluator)?
Definition and Responsibilities
An Agreed Medical Evaluator (AME) is a physician selected by mutual agreement between the injured worker’s attorney and the insurance carrier or claims administrator. The role of the AME is to provide an impartial medical evaluation of the worker’s injuries.
On the other hand, unlike QMEs, AMEs are not certified by the Division of Workers’ Compensation (DWC), though many AMEs may also be QMEs.
Benefits and Legal Implications
One of the primary advantages of using an AME is the potential for expedited resolution of disputes. When both parties agree on a physician, the process for evaluation of injuries and compensation can proceed. The AME’s findings may be binding on both parties, meaning that their evaluation can directly influence the outcome of the claim which can lead to quicker settlements and fewer contested issues.
AMEs are often used when the injured worker has legal representation and both sides can reach a consensus on a physician. Under California Labor Code §4062.2, when a worker is represented by an attorney, he/she can request a panel QME, or their attorney and the insurer can agree to a specific medical evaluator—an AME. One must have an attorney to use an AME.
3. What is a QME (Qualified Medical Evaluator)?
Definition and Responsibilities
A Qualified Medical Evaluator (QME) is a physician who has been certified by the DWC to conduct medical-legal evaluations. QMEs are appointed to provide an objective assessment of medical conditions related to workers’ compensation claims. Labor Code section 139.2 sets forth the law regarding appointment, qualification, termination, guidelines, procedures and admissibility of medical evaluations and submission of reports. Their evaluations help in resolving disputes between employers and injured workers and are essential for determining eligibility for benefits.
Process of Becoming a QME
To become a QME in California, a physician must meet several requirements:
- Licensing: The physician must hold a valid medical license issued by the California Medical Board.
- Certification Exam: The physician must pass a certification examination administered by the DWC.
- Report-Writing Course: The physician must complete a 12-hour course on QME report writing.
Upon meeting these requirements, the physician is appointed by the DWC for a two-year term, during which they are eligible to perform evaluations.
Significance in Workers’ Compensation Cases
QME evaluations are critical in the workers’ compensation system as they provide an unbiased, expert assessment of an injured worker’s condition. The QME’s report serves as a basis for negotiation and helps in determining the extent of injuries and the appropriate compensation. Since QME reports are non-binding, they provide a neutral ground for discussion and are often used to facilitate settlements between the parties involved.
If a party needs to utilize a QME physician for an examination, they will submit a panel request to the DWC, which would produce a panel of 3 QME physicians A panel QME is generated typically from the QME’s around the geographic area where the party resides using their zip code. In order to make the process fair to both sides of the case, both the parties would each eliminate one of the names, leaving one name left, and that QME physician would be the person requested to conduct the evaluation and submit its report.
Spectrum Eval’s Support
Spectrum Evaluators plays an indispensable role in enhancing QME practices by offering comprehensive support services. These services include practice management, administrative assistance, and strategic guidance to help QMEs optimize their practice and achieve success.
4. Key Differences Between AME and QME Legal and Procedural Differences
The key differences between AMEs and QMEs primarily revolve around the selection process and the binding nature of their evaluations:
- Selection Process: AMEs are selected through mutual agreement between the parties involved in the case. In contrast, QMEs are chosen from a panel provided by the DWC.
- Binding Nature: The findings of an AME may be binding on both parties. QMEs provide reports that encapsulate expert opinion which has evidentiary value in court of law. These medical legal evaluations provide a persuasive value to determine compensation to be awarded, if any.
Guidance on Selection
Choosing between an AME and a QME depends on the specifics of the case:
- AME: Ideal when both parties agree on a single evaluator and seek an opinion that may be binding on the parties. This can expedite the resolution process and reduce the need for further disputes.
- QME: Suitable for cases where an objective evaluation is needed. QMEs are used when impartiality and adherence to formal procedures are crucial.
5. Conclusion
Understanding the differences between AMEs and QMEs is essential for effective participation in the workers’ compensation system. Each type of evaluator has its unique role and benefits, and selecting the right one can impact the efficiency and outcome of a claim. Partnering with Spectrum Evaluators provides QMEs with valuable resources and support, optimizing their practice and enhancing their success. Physicians are encouraged to explore QME opportunities and consider how Spectrum Evaluators’ services can benefit their practice and improve their outcomes.
FAQs
What Labor Code sections and regulations pertain to QMEs?
Key Labor Code sections include §139.2, which covers the appointment and qualifications of QMEs, and §§4628, 4060, 4062.1, and 4062.2, which outline evaluation and reporting requirements. QME regulations are detailed in California Code of Regulations, Title 8, Sections 1-159.
Why are medical and non-medical records sent to the QME?
These records provide the QME with a complete history of the injury and treatment, helping avoid unnecessary duplicate tests and clarifying the extent of the disability caused by the injury.
To whom should the QME or AME report be sent?
Reports should be sent to the applicant, their attorney (if represented), and the claims administrator or defense attorney, as specified by the relevant Labor Code sections.
Case Type | Unrepresented QME Labor Code § 4060 | Represented QME Labor Code § 4060 | Unrepresented QME Labor Code § 4061 | Represented QME Labor Code § 4061 | Unrepresented QME Labor Code § 4062 | Represented QME Labor Code § 4062 |
Who gets served? | Applicant | Applicant and Applicant’s attorney | Applicant | Applicant and Applicant’s attorney | Applicant | Applicant and Applicant’s attorney |
Who else is to be served? | Claims Administrator or the defense attorney | Claims Administrator or the defense attorney | Claims Administrator or the defense attorney | Claims Administrator or the defense attorney | Claims Administrator or the defense attorney | Claims Administrator or the defense attorney |
Is Disability Evaluation Unit (DEU) to be served? | No | No | Yes | No | No | No |
What is served? | Medical Report | Medical Report | Document Cover Sheet | Medical Report | Medical Report | Medical Report |
QME Form 111 – QME Findings Summary Form | QME Form 122 – AME or QME Declaration of Service of Medical-Legal Report Form | Document Separator sheet – DWC-CA form 10232.2 | QME Form 122 – AME or QME Declaration of Service of Medical-Legal Report Form | QME Form 111 – QME Findings Summary Form | QME Form 122 – AME or QME Declaration of Service of Medical-Legal Report Form |
How long does a QME have to complete their report?
QME must submit their report within 30 days of the evaluation. Extensions may be granted for good cause, up to 15 days, or up to 30 days if additional information is required.
Can a QME submit a supplemental report?
Yes, a QME can submit a supplemental report within 60 days of the request, with a possible extension of 30 additional days if agreed upon by the parties.
How can I become a QME in California?
Physicians must pass the QME examination, complete a 16-hour report-writing course, and meet other requirements set by the DWC. The examination includes questions on clinical assessment, medical treatment, and legal regulations.
How can I grow my QME practice?
Spectrum Evaluators offer various services to help QMEs streamline their practice and expand their business. For more information, schedule a consultation, and to join the team, visit Spectrum Medical Evaluators and join our team.
