QME Reports: Why do they matter?

In the Workers’ Compensation industry, the various parties involved including raters, attorneys, insurers, employers, and judges, rely on QME (Qualified Medical Evaluator) reports to fulfill their respective roles in the Workers’ Compensation process. Understanding the significance of QME reports from the perspectives of these third parties will further a QME’s report-writing skills.

A disability rater at the Disability Evaluation Unit rates permanent disability after reviewing a medicolegal report describing an injured worker’s condition. The most important part of a report for a rater is to convert an impairment rating to a disability rating, which is used to calculate the financial settlement.  The impairment rating must be consistent with the AMA Guides 5^th edition and relevant case law, citing such laws when used.  A thorough defense of the impairment rating must be provided, as there are often many ways that an injury can be rated, but only one most appropriate method.  Pitfalls to avoid when writing these reports include inconsistency, incorrect use of tables or charts, and failure to provide written rationale for findings.

An Applicant Attorney hopes for a careful and detailed history and physical examination and a thoughtful discussion to ensure that the injured worker is able to receive the benefits they are entitled to under California law. Treating physicians, while they have a doctor-patient relationship with the injured worker, often do not have the time or expertise to address all of the medicolegal issues of a case in the same way that a QME can.  Workers’ Compensation reports highlight medicolegal issues relevant to the case including causation, disability status, impairment, apportionment, and future medical care. Establishment of causation leads to treatment, while establishment of permanent disability allows for future medical care and a financial settlement.  Applicant attorneys use these reports to advocate for injured workers to receive the benefits that they are entitled to, including medical treatment, temporary disability, permanent disability, death benefits, and supplemental job displacement benefits. They assess impairment ratings in relation to functional limitations, sometimes seeking second opinions to challenge ratings that are not in the best interest of their client. The reports are used to prepare legal briefs, arguments, and exhibits for hearings before administrative law judges or appeals boards.  Applicant attorneys advocate for their clients’ rights to fair and adequate compensation based on the extent of their injuries and the impact on their ability to work.

Workers’ Compensation insurance companies rely on QME reports to evaluate the validity of claims, verify causation, and assess the severity of injuries. Reports inform decisions regarding compensation for benefits: in California, an injured worker is entitled to treatment of the injury, temporary disability, permanent disability, and supplemental job displacement benefits.  Temporary disability is paid tax-free at 2/3 the usual rate for a maximum of 104 weeks.  Insurance adjusters analyze the medical opinions regarding causation of injury in conjunction with other evidence to determine the extent to which the employer may be liable for providing benefits. Adjusters use medical evidence to negotiate settlements, implement cost containment strategies, and facilitate return-to-work initiatives.

Employers require QME reports to assess liability, initiate the claims process, and coordinate return-to-work efforts. The time allowed for a QME to delve into past injuries is advantageous for the purposes of apportionment, which a treating physician may be unable to do in a short office visit. Timely and accurate reporting is essential for expediting the claims process and ensuring that injured employees receive prompt medical treatment and benefits as required by law. Employers utilize the report to determine whether the incident occurred arising out of employment (AOE) or in the course of employment (COE). AOE indicates that the injury arose from employment but did not occur during usual job duties, such as an injury sustained during a mandatory company lunch outing. COE indicates that there is proof the injury occurred at the workplace. A QME is responsible for finding causation in the course of employment, whereas a judge is responsible for determining causation arising out of employment. Employers use the information regarding the nature and extent of the employee’s injury or illness to coordinate the employee’s return-to-work process, ensuring that appropriate accommodations are made to facilitate a safe and successful return to job duties. The reports help manage the financial impact of injuries, ensuring compliance with legal requirements and promoting workplace safety.

Judges depend on QME reports as objective assessments of workers’ medical conditions and impairment levels. A judge assesses the admissibility of the report to ensure that it meets the legal requirements for evidence in Workers’ Compensation proceedings. The judge considers the report written by the primary treating physician and a QME when involved.  A report that is late or does not comply with the Labor Code may be rejected.  In a panel QME case, a judge may select either the primary treating physician’s report or the QME report in order to make benefits determinations.  Permanent disability is based off of a disability rating provided by the DEU raters, as calculated from the impairment rating provided by the QME.  By contrast, an AME (Agreed Medical Evaluator) report is always considered to supersede a treating physician’s report.  The reason for this is that both parties have agreed on an expert opinion and to be bound to the conclusions of that AME.  In order to become an AME, a QME must build a reputation for high quality reports that leave both parties satisfied by the outcome.  AMEs enjoy a higher reimbursement rate due to the complexity of the cases they typically receive and their ability to help resolve a dispute.

The judge considers the disability rating, among all other evidence, in determining the worker’s eligibility for benefits, including compensation for permanent disability (1). They evaluate the medical evidence and expert opinions presented in the report to determine whether there is a causal relationship between the work-related factors and the worker’s medical condition. Factors such as the credibility of the examining physician, the consistency of the medical findings, and the persuasiveness of the reasoning in the report are taken into account. Ultimately, the judge considers the information contained in the report, along with all other relevant evidence and legal arguments presented by the parties, in making a decision on the Workers’ Compensation claim. The judge’s decision may include determinations regarding the worker’s eligibility for benefits, the amount of compensation awarded, and any other issues raised in the case.

References:

1. Workers’ Compensation Schedule for Rating Permanent Disabilities. California Workers’ Compensation Institute, May 2008. https://cwci.org/.