Leaving a QME appointment doesn’t mean the doctor has decided your workers’ compensation case. A Qualified Medical Evaluator, or QME, performs an independent medical-legal evaluation to address disputed medical issues. The evaluator isn’t your treating doctor and doesn’t independently award benefits, end a claim, or approve a settlement.
What happens after a QME exam in California depends largely on the written report, the issues it addresses, and the deadlines triggered by its arrival. Understanding those next steps can help you protect your rights and respond through the proper process.
The QME’s Role After the Exam
The QME report often becomes important evidence, but it isn’t the final word in every dispute. The injured worker, attorneys, claims personnel, and a workers’ compensation judge can rely on it when addressing contested issues.
The report may address:
- Whether your condition was caused or worsened by work
- Whether you have reached maximum medical improvement
- Your work restrictions and future medical treatment
- Permanent disability resulting from the injury
Maximum medical improvement means your condition has reached a point where it isn’t expected to improve substantially with further treatment, although you may still need medical care.
How Apportionment Affects the Report
California law requires the QME to address apportionment when evaluating lasting impairment. Apportionment separates the disability caused by the work injury from disability attributed to non-work causes, such as an earlier injury or degenerative condition. If the report assigns symptoms or limitations to a non-industrial cause, compare that conclusion with your medical history and the records the evaluator reviewed.
Deadlines for Receiving the QME Report
For most initial comprehensive evaluations, the QME has 30 calendar days from the start of the examination to prepare and serve the report. Keep the appointment paperwork and record the exam date so you can determine whether the report is overdue.
The evaluator may request additional time in limited circumstances. A request for up to 15 extra days requires good cause, while an extension of up to 30 extra days may apply when the QME is awaiting test results or a consulting physician’s report. The evaluator must request the extension on Form 112 at least five days before the original deadline.
If the evaluator doesn’t serve the report on time and has no approved extension, either side may request a replacement QME. Don’t rely solely on a verbal update from the insurance company. Save the envelope, email, or other proof showing when you received the report because later deadlines can run from that date.
How to Review an Incomplete or Unfavorable Report
Read the report against the underlying record, not just its conclusion. Check:
- The listed body parts and injury date
- Your job duties, symptoms, and prior injuries
- Diagnostic tests and treating-doctor records
- The medical questions the QME was asked to answer
Some problems are factual, such as an incorrect work history or missing diagnostic test. Others involve medical-legal issues, including an omitted body part, unsupported apportionment, restrictions that don’t match the described work duties, or a treatment recommendation that fails to address the disputed condition.
Follow the Formal Correction Process
Unrepresented workers may request a factual correction to a comprehensive medical-legal report within 30 days after receiving it. If the QME failed to address all medical issues and no Disability Evaluation Unit, or DEU, summary rating has been issued, an unrepresented worker can request a supplemental report. The worker must first send a copy of the request to the claims administrator 20 days before writing to the evaluator.
Communication with a panel QME must be in writing and shared with the opposing side. Don’t send the evaluator a private message, new records, or a letter that the claims administrator hasn’t received. A supplemental report can address an omission without another examination, but it doesn’t guarantee that the QME will change an opinion.
From Medical Findings to a Disability Rating
A QME’s findings can move the claim toward a permanent disability rating. Permanent disability is a lasting work-related impairment after the condition has reached maximum medical improvement. California’s disability rules apply to the medical findings, but the resulting rating doesn’t resolve every issue involving treatment, work capacity, or settlement.
For an unrepresented worker, the DEU may issue a summary rating based on the report. After receiving that rating, the worker has 30 days to file a Request for Reconsideration of the Summary Rating using DEU Form 103. Keep the notice with the QME report and document the date it arrived.
If no rating has arrived within 20 days after the report was submitted to the DEU for rating, an unrepresented worker may ask the claims administrator whether it’ll rate the report instead. A requested supplemental QME report generally must be completed within 60 days of a written or electronically transmitted request, although the parties can agree to an additional 30 days. Preserve every report, notice, and proof of receipt so you can track these deadlines.
Possible Paths After the Report
A QME report can narrow a dispute or reveal issues that require further development. Depending on the report and other evidence, the case may proceed through supplemental medical reporting, negotiation, or a hearing before the Workers’ Compensation Appeals Board.
Settlement discussions often follow when the report gives both sides a clearer view of the disputed medical issues. Any workers’ compensation settlement must be approved by a workers’ compensation judge at the Workers’ Compensation Appeals Board.
- Stipulation With Request for Award: This settlement form commonly identifies agreed benefit obligations while leaving specified rights open under the award, such as future medical care for the accepted injury.
- Compromise and Release: This agreement commonly resolves identified claim rights through a negotiated payment, subject to judicial approval. Review its terms carefully because it can affect future rights connected to the claim.
Review the Report Before You Respond
Preserve the report, record when you received it, and seek timely advice before writing to the QME or accepting a proposed settlement. A workers’ compensation attorney can assess whether the opinion addresses the complete medical record, claimed body parts, work duties, and disputed issues.
Our workers’ compensation practice includes reviewing medical records, communicating with doctors, and preparing evidence that connects an injury to the circumstances of employment. Attorney John G. Kiwan founded our firm in 1988, and Attorney Christian Chambers joined in 2014. We serve injured workers throughout Southern California in English and Spanish, with free virtual consultation options and contingency-fee representation.
Call Kiwan & Chambers APC at (619) 257-5304 to discuss the next step in your disputed claim.