If your attorney and the claims administrator cannot agree on which doctor to use, you must then go through the process of choosing a QME. The QME panel you will choose from is a list of approved physicians that were chosen at random.
The physicians on the list must meet educational and licensing requirements to qualify as a QME. You will receive a QME panel request form from the claims administrator and are given the first chance to fill out and submit the form. Whoever fills out the form first to request the QME gets to choose the specialty of the doctors on the panel. If you do not submit the form within 10 days, the claims administrator will do it for you and will get to choose the specialty of the QME you will see.
The QME does have the option, under certain circumstances, to request an extension. After you receive the QME report, there are several things that may happen.
If both you and the claims administrator agree with the treating physician's report there is no need to attend a QME evaluation. My QME evaluation was yesterday. How long does the doctor have to issue the report? The QME has 30 calendar days from the date of the commencement of the exam to issue the report. There are three reasons a physician may request an extension:. The physician may not request an extension because the claims administrator failed to provide your medical records or past medical tests.
If the report is going to be late, the physician must file a time frame extension request with the DWC Medical Unit and send a copy to the claims administrator and to you. This must be filed five days before the report is due. If you don't have an attorney and permanent disability is the disputed issue, the QME will send a copy of the report to the claims administrator, to the Division of Workers' Compensation Disability Evaluation Unit DEU and to you.
The DEU should issue a rating within 20 days. If a rating is not issued within 20 days, you may ask the claims administrator if they would rate the report rather than waiting for the DEU to issue a rating.
Once a rating is obtained, you may begin discussing settlement of your case with the claims administrator. Labor Code sections c ; i. If you have an attorney and permanent disability is the disputed issue, the QME will send a copy of the report to both your attorney and the attorney for the claims administrator. If a permanent disability rating is required, a copy of the report will be sent to a disability rater by either your attorney or the attorney for the claims administrator.
Your attorney should advise you about all the steps in the process. I need another evaluation. Should the original QME do it? What if that physician is no longer performing QME evaluations? The second evaluation should be done by the same QME. The exceptions to this rule are:.
If any exception applies, you may begin the QME request process again and you will receive a new panel. Labor Code sections These records give the QME a history of your injury. The physician's records indicate the diagnosis and treatment received to date. Medical records about treatment prior to the injury are often sent to help determine how much of the permanent disability is due to this injury and how much may be due to a prior injury or accident.
Non-medical records, such as personnel records or films, are sent to provide information regarding the injury to the QME physician. What non-medical and medical records are sent to the QME? Can anyone object to certain records being sent to the QME for review? The claims administrator receives, on an ongoing basis, all the treating physician's reports, copies of x-ray results, and may obtain old medical records that relate to the current injury.
All these are considered medical records. You do not have the right to object to any medical records being sent to the QME. Once you make the QME appointment, the physician has five days to send the QME appointment notification form to the claims administrator advising them of the appointment. The claims administrator is required to send you a copy of everything they plan to send to the QME physician 20 days prior to sending the records to the QME.
You are also required to send any information letters from friends, personal records you are planning to send to the QME to the claims administrator 20 days before you send it to the QME. Both you and the claims administrator or your respective attorneys have 10 days to object to any non-medical records being sent to the QME. There is no form for this objection. Whoever is objecting simply writes a letter to the other party. If either you or the claims administrator does not follow the day rule, the wronged party has the right to cancel the evaluation.
What should be done? What should I do if the claims administrator is objecting to one of the QMEs on my panel because the doctor treated or evaluated me, is in the same office as my treating physician or is my primary treating physician?
Any physician who has served as the primary treating physician for this injury may not be your QME. However, the Medical Unit will not replace a QME just because you saw him in the past for some other problem. A QME is required to disqualify himself when he has served as your primary treating physician.
Box , San Francisco, CA , or you can make an anonymous complaint by calling the Medical Unit's hotline at The Medical Unit prefers to have your name and address or phone number so that it can reach you if there are questions. The QME did not issue the report and it's been over two months. What recourse do I have? If an extension was not requested or if the extension requested was denied, you can continue to wait for the QME report to be issued if you wish.
If you don't want to wait, the Medical Unit will issue a new panel. In this case, either the claims administrator or you should contact the original QME and tell him not to issue his report as his bill will not be paid. You might request a QME exam if:. One physician from the list is chosen to examine you and make a report on your condition.
Each QME panel is randomly generated and the physicians listed are specialists of the type requested. If you have an attorney, your attorney and the claims administrator may agree on a doctor without going through the state system used to pick a QME. The doctor your attorney and the claims administrator agree on is called an agreed medical evaluator AME. QME lists are generated randomly.
Whoever submits the request form picks the specialty of the doctor that does the exam. The doctors are selected randomly and will be as close as possible to your home address.
When you receive the panel, you will also receive a letter that explains how to set up the QME appointment and how to provide the QME with important information about yourself. When you receive the report, read it right away and decide if you think it is accurate. If not, and you have an attorney, you should talk to him or her about your options. See below for contact information. If you are in a union, you may be able to see an ombudsperson or mediator under the terms of your collective bargaining agreement or labor-management agreement.
If your MPN doctor requests treatment that you agree with and that treatment gets denied under utilization review UR , you have the right to be evaluated by a QME. The claims administrator must advise you of this right. First, you can change to another physician on the MPN list. You can also ask for a 2nd and 3rd opinion from a different MPN doctor.
If you still disagree, you can have an independent medical review IMR to resolve the dispute.
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