Qualified Medical Evaluator (QME) vs Agreed Medical Evaluator (AME)

If you were injured in a work-related accident in California, you may be entitled to receive workers’ compensation benefits through your employer’s workers’ compensation insurance. Besides paying temporary disability benefits for lost wages during the time you are unable to work, these benefits also cover the expenses of the medical evaluator, current health treatments, and certain future treatments. 

If there is a dispute regarding which workers’ comp benefits you are entitled to and the value of those benefits, a neutral medical evaluator will be used by both you and the employer’s insurance company. The type of medical evaluator assigned to your workers’ compensation case depends on the facts and likely whether you have an attorney representing you.

In California, you can have your attorney and the employer’s insurance company decide on an agreed medical evaluator (AME). In other instances, the state may assign you a qualified medical evaluator (QME). Learn the differences between these two evaluators when you are seeking workers’ compensation.

What is a Qualified Medical Evaluator?

A QME in California is a physician, dentist, psychologist, or acupuncturist who has undergone training and been certified to evaluate workers’ disabilities and create medical-legal reports, which are used to determine workers’ eligibility for benefits, according to the California Department of Industrial Relations. They must pass a test regarding the workers’ compensation evaluation process to become certified by the Division of Workers Compensation (DWC) Medical Unit. Once certified, the doctor’s name is placed in the Qualified Medical Evaluator database, which is used when a party involved in a workers’ compensation case requires the assistance of a QME.

When there is a dispute between you and the claims administrator regarding whether you suffered a compensable injury or the degree of your disability, and you do not have an attorney to negotiate an AME, then the DWC Medical Unit will generate a panel QME upon request, based on California Labor Code §4062.1. You or your employer also can request a panel QME if you are represented by an attorney. 

The insurance claims administrator should provide you with a panel request form. If you do not submit the form electronically within 10 days, the administrator will do it for you. Whoever submits the panel request form has the ability to choose the medical provider’s specialty, which dictates which type of doctor you will see.

A panel QME is a randomly generated list of three state-certified doctors, typically in the geographic area where you live, though other locations may be used. Once you receive the panel QME, if you are not represented by a lawyer, you have 10 days to select a QME. If you fail to do so, your employer will make the selection on your behalf, and you will be required to see that QME. If you have an attorney, then you and your employer each strike a name from the list, and you must see the remaining QME.

After a QME is selected, you must schedule an exam. Within 30 calendar days of the start of the exam, the QME must issue a report regarding your injuries. The report may draw conclusions regarding whether your injury arose from a workplace accident, the extent of your injury, whether you can work, whether your condition is permanent, and whether you are suffering from a new disability. 

What is an Agreed Medical Evaluator?

Under California Labor Code §4062.2, when you are represented by an attorney, you can request a panel QME, or your attorney and the insurer can agree to a specific medical evaluator—an AME. You must have an attorney to use an AME. Your AME will be a doctor who is chosen to perform the medical evaluation independently. 

If you have an attorney and you both decide to select AME, you will not have a QME assigned to your case. The doctor who is chosen to be the AME must also have training and education in workers’ compensation benefits and workplace-related accidents and injuries to be able to perform the requested evaluation. The doctor may be a certified QME but does not have to be. 

Getting the Workers’ Compensation That You Deserve

Many people can become worried that a QME may not provide an impartial evaluation and will instead side with the employer’s insurance company regarding the extent of your injury or illness, which could lead to obtaining lower benefits or a denied claim. To give you greater peace of mind about the medical examination, or to have an AME create the necessary med-legal reports, it is advisable to seek out a workers’ compensation attorney. The attorney can evaluate your case and help you decide on the doctor and specialty that would be able to perform a thorough examination.Here at Appel Law Firm LLP, we are personal injury attorneys as well as workers’ compensation lawyers who can look over your claim and help you determine your rights. Contact us today to schedule a consultation.

Speak Your Mind