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What is Qualified Medical Evaluation?

A qualified medical evaluation is a process of evaluating an injured worker seeking a workers’ compensation claim by a qualified medical examiner (QME). A QME is a physician who has certification from the Division of Workers’ Compensation Medical Unit (DWC) to evaluate injured workers and determine eligibility criteria for workers' compensation benefits. Any medical practitioners, such as medical doctors, psychologists, chiropractors, and acupuncturists, can become a certified QME upon clearing the QME Competency Exam conducted by the DWC Board. After passing this exam, the medical practitioner should also complete a course on disability evaluation report writing as QMEs are expected to write medical-legal reports after evaluating the worker for determination of work status, including light or modified duty, maximum medical improvement (MMI), permanent and stationary (P&S) status, permanent disability, etc. The reports are utilized to establish an injured worker's eligibility for workers' compensation benefits.

What is Workers’ Compensation?

In an unfortunate incident, where a worker becomes injured while working or develops a work-related illness, the worker should report to their employer who then files for Workers Comp claim.

Workers Comp is an insurance program that protects both the worker and the employer. The employer pays a premium every month toward Workers Comp insurance coverage for every worker. If the premium is unpaid, the employer could end up paying hefty medical and legal bills in case of an unfortunate injury to the employee at the workplace. The injury can be any work-related injury or an illness arising out of employment (AOE), such as slips and falls at work, lifting heavy weights, repetitive motions while performing job duties, accidents while driving for business, skin injury caused by exposure to chemicals at work, or lung injury caused by inhaling toxic substances at the workplace.

The employee benefits include wages for lost work time and reimbursements of medical expenses during the recovery period, including therapies (occupational therapy, physical therapy, psychotherapy, acupuncture therapy, chiropractic therapy, etc.) for regaining the range of motion or other healing activity of the patient. Workers Comp will offer benefits until the employee can resume work. Worker comp’s no-fault coverage ensures that the worker remains protected even if the worker’s negligence caused the injury at work. Workers Comp is also responsible for paying permanent disability benefits if the injury is deemed permanent.

When is a Worker Required to See a QME?

Your workers’ comp claims adjuster may request you to see a QME if there are any questions regarding your workers’ comp claim, such as whether you were injured, the extent of your injury, what treatments you should receive, whether you can return to work, and what benefits you will need to be paid. If you get a permanent disability rating, you will probably be referred to a QME. The QME will carry out an evaluation and establish whether they agree with your treating doctor about any particular issue in dispute. Your primary treating doctor under workers' compensation provides you with treatment. The QME is designated with providing a second opinion.

Why is Qualified Medical Evaluation Important?

When a worker is injured, he or she normally visits their primary care provider who determines the extent of the injury and condition and recommends “time off from work” accordingly to recover. However, disagreement often arises between employees and employers over the level of an injury/disability and what benefits are owed. In such circumstances, a QME is sought to provide an unbiased professional opinion. Qualified medical evaluations are a crucial part of the workers' compensation process as QMEs have been specially trained to examine injured workers and offer an impartial assessment of the condition. QMEs will speak to the injured workers about their injuries and symptoms, review their medical records, and may even conduct a physical examination. Based on this information, the QME will provide an unbiased opinion as to the severity of the injury, if you have any permanent disability, what future medical care you may need, and what other benefits you are entitled to.

What is the Significance of a Qualified Medical Evaluation Report in Relation to Workers’ Compensation Claims?

After preparing the qualified medical evaluation report, the QME will submit the report to the Workers' Compensation Appeals Board. This report can either hurt or help the claim of the worker based on the severity of their injuries. If the QME discovers that the worker has a serious injury, then the worker will likely be entitled to receive more benefits. However, if the QME discovers that the injuries are not as severe as claimed by the worker or their primary care provider, then the worker may receive minimal benefits or none at all. It is important to remember that qualified medical evaluations are only one part of the workers' compensation process. The opinion of the worker’s primary treating physician will also be considered while making a decision about the benefits a worker is entitled to as per the Workers Comp claim.