AMEs perform essentially the same duties as QMEs, and yet make 35% more per encounter. They enjoy steady income streams and are permitted to retire from clinical practice while continuing QME and AME work. AMEs aren’t even required to pass an exam or maintain QME certification. Why are AMEs given this privileged position among those opinions on contested Workers’ Compensation cases? These respected experts have established a reputation of being predictable and neutral, with both parties agreeing to be bound to their opinions. Essentially, they are a known entity that is trusted to be fair in their assessment of industrial injuries.
Qualified Medical Evaluator (QME)
A QME is a physician who has been appointed by the State of California to perform neutral examinations of injured workers and settle a dispute between the injured worker and the employer. QMEs submit reports for the judge to review and recommend Workers Compensation benefits such as treatment and impairment. This protects employees from unreasonably denied claims and employers from unsupported claims. These reports also support or refute eligibility for Workers’ Compensation benefits, which can include medical treatment, temporary and permanent disability benefits, and vocational rehabilitation.
When a QME is requested, the requesting party can select the specialty of the physician. For example, a low back injury can be sent to Orthopaedic Surgery/Neurosurgery Spine, General Orthopaedic Surgery, Physiatry, Pain Management, or Chiropractic. The selection of specialty is beyond the goals of this commentary, but entails complex factors such as the reputation and biases of the specialty as a whole or the local QME pool. The State then generates a panel of three physicians in that specialty with locations near the injured worker’s home address. Each party may then strike one physician out from the 3-physician panel, leaving the Panel Qualified Medical Evaluator assigned to the case.
To be selected on a panel, a QME physician must pass the written examination, complete a certified report writing course, and engage in continuous education in order to maintain their appointment. QME appointments must be renewed every two years.
A QME’s opinion and Primary Treating Physician’s opinion hold equal weight by the judge, and either report may be selected as the basis for decision-making.
Agreed Medical Evaluator (AME)
AMEs are mutually agreed upon by both the injured worker and the employer’s insurance company or their representatives, and the format of the reports is identical to the format of a QME report. AMEs are selected when both parties agree on an evaluator. Because both parties mutually consent to an AME, their decision holds greater weight in the eyes of a judge. An AME’s report outweighs a PTP report. While a QME’s opinion remains influential in benefit determinations, an AME’s assessment expedites case resolution, potentially expediting compensation.
AMEs enjoy preference by both parties for their predictability and neutrality. The AME can be chosen either with or without a panel generated. It is required for the applicant to be represented by an attorney to be able to use an AME; an unrepresented applicant is only permitted a panel selection. AMEs do not need a QME license or to pass an examination in order to perform evaluations, but have significant experience. A billing modifier is used to compensate an AME 1.35x relative to an identical QME report.
The QME system in the state of California obviates the need to go to court, as standardized reports are submitted directly to the Trier of Fact. AMEs further enjoy increased reimbursements and are held in higher esteem by the system, with reports that hold greater weight than a PTP report. QMEs should aim to provide reliable and neutral reports for their own integrity and care for each case, but may find themselves selected to be an AME when they establish a reputation for fairness that is consistently within California law.