As a QME, you will receive a cover letter for nearly every report you’re expected to write, including Initial Evaluations, Re-evaluations, and Supplemental Reports. Reading a cover letter for a case is one of the first skills a QME should develop, especially as cover letters vary greatly in the amount of information provided.
We strongly recommend reading a cover letter at least one day before a QME appointment, so that there is no rush and no surprise.
Make note of the author of the letter, and what their role is: insurance adjustor, applicant attorney, or defense attorney. Understanding the role will inform your understanding of the request.
You’ll notice that cover letters reference case numbers, including a Workers Compensation Appeals Board (WCAB) number, which begins with ADJ. If more than one number appears, there will be multiple claims to evaluate, you as a QME must evaluate the applicant in both history and physical examination for all the claims. Typically, the body of the letter goes into detail about each of the claims. Each of these must be referenced in the cover letter of your report, which is likely done by clerical staff.
The dates of the claimed injuries are important. If there is a single date, that indicates a specific injury, and if there is a date range, that indicates a cumulative trauma. Oftentimes, cumulative traumas are only documented as the final year of employment, but are implied to have occurred over the entire course of employment. You will need to verify dates and mechanisms of injury with the injured worker, so it is helpful to make notes of these dates and claimed body parts corresponding to those dates prior to the evaluation.
Being aware of each body part claimed is very important. Some cover letters are more thorough than others. A very helpful cover letter will include all body parts for every claim, and also note which body parts or dates of injury were accepted and which were denied, and why. This is not always the case, however. Sometimes, a cover letter only indicates the accepted body parts. It is very important in this case to check this against other cover letters or the applicant’s history to ensure no denied body parts are omitted in your report. When a body part is denied, that does not mean you do not need to evaluate this body part. Keep in mind that QMEs settle disputes, so nearly all evaluations have a dispute in regards to the claim. For this reason, it’s likely that the purpose of your visit is to thoroughly obtain a history and physical examination of injuries denied by the insurance company/employer.
A complete QME report will generally answer all of the generic interrogatories (specific questions from the attorneys). However, keep an eye out for questions unique to the case. The cover letter may also include prompts for prior injuries, and it is very important to get a detailed history of all prior injuries for the purposes of apportionment and causation. We recommend taking notes on these in advance, and verifying the facts in your history with the applicant.
It is helpful to keep these cover letters open while taking a history with the injured worker to ensure that you are addressing all pertinent points of the case. When in doubt, recall that you are being asked to settle a dispute, so if there is a question of injury, it’s best to investigate it thoroughly.