Most QMEs are conscientious physicians who attempt to submit thoughtful reports for cases of contested work injury. The Workers’ Compensation Appeals Board (WCAB) handled 107,700 medical-legal reports on all claims that were issued and only rejected 81 reports over a one-year span, from November 2020 to November 2021 (1). This comes after a finding by the WCAB in 2016 that determined 85% of QME reports from a select sample in California were of poor quality, (2). Recent conversation with a DWC Rater provided insight into typical pitfalls of a rejected report.
QMEs and physicians provide impairment ratings that are used in calculations by professional Raters at the DWC to provide disability ratings. For a DWC rater to be able to provide a disability rating, the report must be of high quality and have key features. A report may not be ratable because an applicant is not yet at maximal medical improvement. However, if a QME has determined the applicant to be at maximal medical improvement and provided an impairment rating along with all of the other required conclusions of a QME report, a report may be considered unratable by the DWC if there are quality or content issues.
While less than one in one thousand reports were rejected by the DWC, it is important to note the most common reasons for a report to be rejected, which are easily avoidable by an experienced QME.
Inconsistency with AMA Guides and State Law
Inconsistency of the report with the AMA Guides 5th Edition will immediately flag this report as unacceptable. Lack of understanding of tables and charts that are very familiar to DWC raters, adjustors, and attorneys will be apparent on initial read. A written defense of all conclusions is also necessary.
Any required references to California Labor Code and relevant case law must be addressed and discussed. A report may be rejected with no payment justified simply for omission of appropriate Labor Code.
Inadequate Physical Examination and Documentation
Improper use of grip strength for impairment rating purposes is a common pitfall in the upper extremities. Strict adherence to the physical examination techniques laid out in the guides and use of the required measurement instruments for each physical examination maneuver is essential for both upper and lower extremities. Physical examination techniques must also be documented, such as use of maximal measurement versus average measurement when appropriate, use of proper tools such as spinal inclinometer, Jamar grip strength gauge, proper instruction and warm-up, and other key features of the required physical examination (3).
Inappropriate Impairment Ratings
There are typically many different ways to rate an injury, and the selection of one method over another must be defended. In the spine, impairment ratings are conducted by either the diagnosis itself or by range of motion. The Diagnosis-Related Estimate (DRE) is the default method for a distinct injury with single-level involvement, multilevel degenerative disc disease without radiculopathy, and/or corticospinal tract involvement. The Range of Motion (ROM) technique is used in the presence of radiculopathy or multilevel involvement in the same spinal segment, and is considered to be useful when the DRE method is inadequate.
What Happens with Unratable Reports?
Reports that are unratable due to errors on the part of the QME require clarification from the QME in the form of a supplemental report or re-evaluation. These scenarios delay both the rating and settlement processes, further postponing the injured worker’s receipt of benefits which also increases costs to the system. If a report fails to meet minimum standards, a Workers’ Compensation judge may order a supplemental report or a deposition, but it’s also possible in egregious cases for a new panel to be assigned. A reputation of being dismissed from cases can lead to audit and revocation of the QME’s license.
Tardiness
Late reports may not be considered, and a QME may lose his or her license with as few as three late reports. In-person evaluations must be postmarked by 30 calendar days from the date of evaluation, and supplementals must be postmarked by 60 days after the date of either the cover letter or the declaration, whichever is later. In the event of late records received after an in-person evaluation, that supplemental is due to be postmarked by 60 days after date of receipt.
OrthoLegal stands by its motto of Quality, On-Time reporting. Our team will ensure that you are well-trained in report writing and equipped to produce high quality reports from your first day, whether you are an experienced QME or new to the work.
References
- CHSWC 2022 Annual Report. State of California Department of Industrial Relations, Dec. 2022, www.dir.ca.gov/chswc/Reports/2022/CHSWC_AnnualReport2022.pdf.
- Audit Results. Auditor of the State of California, 19 Nov. 2019, www.auditor.ca.gov/reports/2019-102/auditresults.html.
- Cocchiarella, Linda, and Gunnar B. Andersson. AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition, 2001, 2001, https://doi.org/10.1001/978-1-57947-085-2.
