Qualified Medical Exams (QME)
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A California Qualified Medical Examiner (QME) is a medical provider who has been certified the Division of Workers’ Compensation (DWC) by passing an administrative exam. The examination is non-specialty specific, meaning, there are no questions about medicine on the exam. The medical doctors are board certified in a specialty, and must pass this test, in addition to completion of a 12 hour report writing program to become eligible to become a QME.
A Qualified Medical Examiner is NOT required to demonstrate competency in AMA Guides impairment rating as part of the certification process. Upon completion of the DWC requirements, the doctor becomes listed as available for performing QME exams in their listed medical board specialty. The QME must complete 12 hours of continuing medical education approved by the DWC every two years to remain active.
The practical purpose of the California QME system is to offer timely evaluations of claims that are in some level of dispute by the parties (i.e. the injured worker or the insurance carrier). The exam is to be scheduled within six weeks of the appointment call. This allows the insurance carrier time to get the chart records necessary to aid in the exam.
A panel qualified medical exam is a QME exam that is performed based on a choice of three examiners whose practice locations are nearest the injured workers’ zip code. The goal of the panel QME exam is to allow the parties access to objective evaluators who will consider the dispute and offer an opinion, in hopes of resolving the issue and moving the claim along toward appropriate treatment, or settlement.
How it works:
First the QME performs a history, physical examination and a review of medical records as provided by the insurance carrier. The QME then writes a standardized report that addresses the basic considerations of a workers’ compensation claim. The QME must address include: causation, permanent and stationary status, an impairment value calculation (if the case is found permanent and stationary), the need for ongoing treatment, and apportionment.
The DWC will recognize the length and complexity of the exam by designating Medical Legal (ML) codes to the title of the report. A QME examination is designated as a ML-102, ML-103 or ML-104. This designation is often included in the heading or title of the exam. The ML code designation is based on a combination of time and complexity of issues. The complexity issues may sometimes be referred to as “bona fide” issues. These are the issues that support the ML codes. A ML code may also have modifiers. These are codes that follow the ML designation.
The most common modifier is a -95, which designates the report as a panel select QME examination. The second being a -93, which indicates an interpreter was used during the interview of the QME exam. Together, the combinations of the ML designation, along with modifiers, communicate the complexity and circumstance of the examination to the reader.
The Qualified Medical Examiner is required to serve a copy of the QME report to the injured worker, the insurance carrier, and if permanent impairment or disability is address, to the local Disability Evaluation Unit (DEU) within 30 days of the appointment visit.
If there are no other issues to be resolved and the parties are satisfied with the QME opinion, the role of the QME may conclude. However, if further diagnostic testing or chart documentation is required, the QME may delay opinion pending the receipt of more information in the form of a supplemental report (ML-106). For more information on QMEs and Qualified Medical Exams, visit the California Division of Workers’ Compensation, or email us at info@PR4Report.com.
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