Requesting an Additional QME: A 60-Second Seminar in Workers’ Compensation Claims Handling

Due to the nature of certain industrial injuries, there are times during the life of a workers’ compensation claim when an injured worker may require QME examinations by physicians specializing in different fields of medicine. 

For example, a worker with alleged foot, ear and heart injuries will probably require evaluations by a podiatrist, otologist, and cardiologist, as one would not expect each physician to comment outside their specialty.  The purpose of today’s blog is to discuss the procedures governing multiple QME appointments.

The regulations describe two entirely different procedures when an additional QME is required, depending on whether the injured worker is represented by counsel.

1. Represented Injured Workers:  Should one or both parties request an additional QME panel the controlling regulation to be followed is CCR §31.7, which states the applicant should return to the original QME for a supplemental evaluation unless the QME or the parties agree that a different medical specialty is necessary.  If so, then a joint letter is to be submitted along with DWC form 31.7 to the Medical Unit requesting a supplemental panel.  In the joint letter both parties are also to agree on the medical specialty of the supplemental QME.  Again, the parties must agree on both the necessity of a second panel and the medical specialty.  If a dispute arises over either the necessity of a new panel or the medical specialty, then the matter is to be resolved by the workers’ compensation judge.

2. Unrepresented Injured Workers:  When an additional QME panel is required for an unrepresented worker the procedure to be followed is more cumbersome.  Per CCR § 31.7(b)(4) the parties must confer with the Information and Assistance Officer and explain the need for an additional panel.  Proof must then be submitted showing that it is inappropriate for the original QME to address the issue at hand.  Usually, a letter from the original QME recommending that a secondary opinion be obtained from a physician in a different medical specialty will suffice.  The parties are also required to reach a joint agreement in the presence of the I&A Officer on the medical specialty to be requested.  Conferring with the I&A Officer can be done in person or by conference call.  Afterwards, the I&A Officer submits the request for an additional panel directly to the Medical Unit using DWC form 31.7.

Once a supplemental panel is issued all the traditional rules pertaining to med/legal appointments apply.  In litigated claims both sides are to strike a physician from the panel with the remaining physician becoming the QME, while in unrepresented claims the injured worker selects the QME from the list.

We are aware that certain applicant attorneys are requesting additional QME panels and selecting the medical specialty without first consulting with the claim’s administrator.  Such action is in violation of the regulations, yet many administrators are uncertain how to respond.  If anyone is experiencing this problem, we urge you to partner with F+B to challenge both the necessity and medical specialty of an additional QME panel.  Also, if an additional QME report currently exists that was procured in violation of the regulations, it’s not too late to act.  We are ready to work in your behalf to seek its disallowance. We are here to help!