Introduction
Qualified medical evaluators (QMEs) are qualified physicians certified by the Division of Workers Compensation (DWC) to evaluate injured workers and determine eligibility criteria for employee benefits.
Any medical practitioner, including medical doctors, chiropractors, acupuncturists, and psychologists, can become a certified QME upon passing the QME Competency Exam conducted by the DWC Board. Upon clearing this exam, the medical practitioner should also complete a course on disability evaluation report writing as QMEs are required to write medical-legal reports after evaluating the worker for determination of work status such as light or modified duty, permanent and stationary (P&S) status, maximum medical improvement (MMI), permanent disability, and so on.
Workers Compensation
In an unfortunate case, such as a worker who becomes injured while working or develops a work-related illness, the worker should bring it to the employer’s attention with a detailed injury report, called Doctor’s First Report of Occupational Injury or Illness. This needs to happen within a specific period of time, which varies from state to state. The employer then files the Workers Comp claim with the WC Board. If the worker delays reporting the injury or illness to the employer beyond this time, they could lose their benefits.
Workers Comp is an insurance scheme that protects both the employer and the worker. The employer pays a premium every month toward Workers Comp insurance coverage for every employee. If the premium is not paid, the employer could be left paying for some hefty legal and medical bills in case of an injury to the worker at the workplace.
Coverage
The injury can be any work-related injury or an illness arising out of employment (AOE), such as repetitive motions while performing job duties, lifting heavy weights, accidents while driving for business, slips and falls at work, lung injury caused by inhaling toxic substances at work, or skin injury caused by exposure to chemicals at the workplace.
The employee benefits include wages for lost work time and reimbursements of medical expenses during the recovery phase, including therapies (physical therapy, occupational therapy, psychotherapy, chiropractic therapy, acupuncture therapy, etc.) for regaining the range of motion or other healing activity of the patient. Workers Comp will provide the benefits until the worker can resume duty.
Worker comp’s no-fault coverage ensures that the employee remains protected even if the employee’s negligence caused the injury at work.
Workers Comp is responsible for paying permanent disability benefits if the injury is deemed permanent.
QME – Qualified Medical Examiner
A Qualified Medical Examiner is usually brought into the proceedings to resolve any medical disputes in the Workers Comp case. These disputes can be about whether the injury is work-related or if there is a medical issue (medical negligence) not resolved by the primary treating physician’s (PTP) final report. The employee will be given a list of three QMEs from a panel (Panel QME) at the time of the request, depending on the specialty of medicine their injury falls under, such as orthopedics or dermatology.
The Process
The QME will be given a copy of the worker’s medical records that pertain to the accident, injury, or illness. The qualified medical examiner will do a thorough medical records review consisting of injury history, past medical history, past surgical history, family history, review of systems, social history including cigarette and alcohol use history, lab reports, diagnostic studies, impression, assessment, and recommendations from previous treating physicians over the years.
The QME will also perform a focused physical examination to ascertain the degree of functional deficit the affected body part has suffered from the current occupational injury and prepare an impairment summary.
The QME will have a detailed discussion with the patient regarding the nature of the accident or injury and its aftereffects, such as the inability to return to work because of pain or even posttraumatic stress disorder (PTSD). The physician can also recommend vocational rehab if they feel the worker cannot return to work due to disability.
If the examiner deems further diagnostic procedures or lab studies to determine the extent of injury, he or she will order further investigations and will submit a supplemental QME report to the WC Board after examining the test results. The qualified medical examiner must present their report within 30 days to the worker’s attorneys or the claims administrator.
The Settlement
Once the qualified medical examiner submits the report, the Disability Evaluation Unit (DEU) will rate the report within 20 days of submitting the report. The attorney then takes over the legal proceedings toward the settlement of the case.
If the worker or the attorney disagrees with the ratings from the DEU, they can negotiate a compromise with the stakeholders or reach out to a DWC officer to discuss their options. If a permanent disability rating is required, the attorney will advise the employee about all the steps in the process.
PreludeSys Experience
For more than two decades, PreludeSys has been delivering abstracts from the patient’s voluminous medical records, including AME and QME reports, in an easy-to-use summary for the Workers Comp attorneys to promote a client’s case quickly.
PreludeSys is an ISO 27001:2013 certified outsourcing provider for medical record review services. Our services include:
- Follow-up on subpoenas and the collection of records
- A case-focused medical record indexing
- A well-constructed medical record review summary
- Quick turnaround time
- Data security with encryption and HIPAA compliance
- Competitive prices
