Qualified Medical Evaluators (QME), Agreed Medical Evaluators (AME) and Independent Medical Examiners (IME) are physicians who are certified by the California Division of Workers’ Compensation Medical Unit to examine injured workers and provide medical-legal reports to help to guide settlement of a workers’ compensation claim.
The QME reports are used to help determine an injured worker’s eligibility for workers’ compensation benefits.
Psychological injuries (also called Psyche claims), can arise from a variety of stressors in the workplace such as sexual or supervisory harassment, a hostile work environment, or trauma such as a robbery or a shooting. A psychological injury can also arise from a physical injury in the workplace such as orthopedic injuries or burns. Chronic pain arising from these injuries can cause depression, anxiety, sleep disturbances and other related problems.
Physicians who evaluate Psyche claims are generally psychiatrists or psychologists. The QME must analyze how these injuries affect a worker’s overall psychological functioning. The QME also has to consider the special State of California rules and regulations that apply in such cases.
Most QMEs are decided upon by a “strike panel”, which means the attorneys of both the applicant and the employer will receive three names randomly generated from the Division of Workers’ Compensation and each attorney is allowed to cross one name off of the list and whatever third name is left is the QME who is assigned to complete the evaluation.
Thus, the QME is a neutral party and it is the QME’s job to fairly assess all of the issues in the case and generate a thorough report to be provided to both parties.
A more detailed overview of the QME process is available at the following link: www.dir.ca.gov.
Get valuable information on the Medical Treatment Utilization Schedule (MTUS).
An Agreed Medical Evaluator or AME, isa doctor chosen by the worker and their attorney, that claims administrator has mutually agreed to resolve psych claims as described above. Under California Workers Compensation law, AMEs may only be used by a claimant if they are represented by an attorney. They may be evaluated at any location close to the claimant.
An Independent Medical Exam or IME is defined as “the evaluation of an injured party that utilizes a third party, an independent medical professional, to issue an unbiased opinion on the injury.”IMEs role in California workers’ comp cases, arise possibly when there is a dispute over an issue in your claim. IMEs may be used to resolve questions such as whether you can return to work, if your psychological illness or injury is in part work-related, and even if you require ongoing psychological therapy.
When a Panel QME report is scheduled, the applicant will receive information regarding the date, time and place for the evaluation to occur. The office where the evaluation will be conducted is often within 5 miles of the applicant's home address.
On the date of the evaluation, the applicant will arrive at the office and psychological interview is performed following guidelines from §43 of Title 8, California Code of Regulations. Following these guidelines assures that the clinician has conducted the evaluation in a manner consistent with the requirements of the California Labor Code.
Parts of the interview include a psychosocial history, medical history, legal history, educational history, occupational history, mental health history, history of the injury, work status and psychological testing.
The evaluation process can take from 4 to 6 hours. In addition to the interview, the applicant completes a battery of psychological tests that assess a person’s general complaints about current emotional and possibly physical functioning. The test battery always depends upon the reason for the referral, i.e. whether the claim is a psychological stressor only, or if it includes both physical and emotional complaints.
The psychological tests provide objective data for an evaluation so that any diagnosis and level of symptom severity concluded by the evaluator is not purely based on a doctor’s observations or a patient’s self-reports. In addition, because the tests are standardized and subjected to rigorous psychometric evaluation, test findings provide greater reliability and validity.
It should be noted that prior to the evaluation, the evaluator generally receives and reviews medical or personnel records pertaining to the claim in question. The records help determine how much of the applicant’s condition and later permanent disability are due to the current injury and how much may be due to prior events. The applicant should be aware the employer is only responsible for any portion of the psychological injury that was caused by or occurred during the course of employment.
The QME has 30 days from the evaluation date to complete and submit the report to the requesting parties, typically the adjuster, defense attorney and applicant attorney.
FAQ about QMEs at the DWC at the following link: www.dir.ca.gov.
Get more information on the Medical Treatment Utilization Schedule (MTUS) here.
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