QME vs. AME in California Workers’ Compensation: What’s the Difference?

Medical evidence can determine whether an injured worker receives California workers’ compensation benefits and how those benefits are calculated. When the injured worker and the insurance company disagree about an important medical issue, the dispute may require an evaluation by a Qualified Medical Evaluator (QME) or an Agreed Medical Evaluator (AME).

Although QMEs and AMEs both perform medical-legal evaluations, they are selected differently. Whether you are represented by an attorney can also determine which process is available.

Understanding the difference matters because the evaluator’s opinions may affect whether an injury is considered work-related, temporary disability benefits, permanent disability, work restrictions, future medical care, and the eventual resolution of the claim.

What Is a Medical-Legal Evaluation in California Workers’ Compensation?

A medical-legal evaluation is different from ordinary medical treatment.

Your primary treating physician is responsible for treating your injury and issuing reports about your medical condition. A QME or AME generally becomes involved when there is a dispute over a medical issue that cannot be resolved through the treating physician’s reports.

A QME or AME may be asked to address issues such as:

• Whether employment caused or contributed to the injury
• Whether particular body parts are work-related
• Whether you can perform your regular job
• Whether temporary work restrictions are appropriate
• Whether your condition has become permanent and stationary or reached maximum medical improvement
• Whether you have permanent impairment
• What permanent work restrictions are appropriate
• Whether future medical treatment may be necessary
• Whether some portion of permanent disability should be apportioned to other causes

The evaluator does not simply decide whether you are injured. The evaluator is expected to provide medical opinions addressing specific issues within California’s workers’ compensation system.

What Is a QME?

A Qualified Medical Evaluator, or QME, is a medical professional certified by the California Division of Workers’ Compensation Medical Unit to perform medical-legal evaluations.

The state certifies QMEs in several specialties. Depending on the medical issue involved, a QME may be a medical doctor, osteopathic physician, chiropractor, psychologist, dentist, optometrist, podiatrist, or acupuncturist.

QMEs must satisfy applicable licensing and educational requirements, pass the state’s QME examination, and comply with continuing-education requirements.

When a QME performs an evaluation, the evaluator typically reviews relevant medical records, discusses the worker’s history and symptoms, performs an examination when appropriate, and prepares a written medical-legal report.

More information about the QME system is available from the California Division of Workers’ Compensation.

When Might You Need a QME?

You may need a QME when there is a dispute involving a medical issue in your workers’ compensation claim.

Common examples include disagreements about:

• Whether an injury arose out of your employment
• Whether a particular medical condition was caused by work
• Whether you remain temporarily disabled
• Whether you can return to regular or modified work
• Whether you have reached maximum medical improvement
• The extent of permanent impairment
• Permanent work restrictions
• Future medical care
• Apportionment of permanent disability

A QME evaluation can therefore become one of the most important stages of a disputed California workers’ compensation claim.

Are Treatment Denials Decided by a QME?

Treatment denials are not always decided through the QME process.

When a treating physician recommends medical treatment, the request is generally reviewed through California’s utilization review process. If utilization review modifies, delays, or denies treatment based on medical necessity, the worker may have the right to pursue Independent Medical Review, commonly called IMR.

A worker generally cannot use a QME simply to overturn a utilization review determination regarding the medical necessity of requested treatment.

However, a dispute that appears to involve “treatment” may actually involve another issue. For example, the insurer may dispute whether the injured body part is accepted, whether the condition was caused by work, or whether the requested treatment relates to the industrial injury.

The reason for the denial matters. The proper procedure depends on the particular dispute.

How Is a QME Selected If You Do Not Have a Lawyer?

An injured worker who is not represented by an attorney generally receives the first opportunity to request a QME panel after being notified of a qualifying medical dispute.

The California Division of Workers’ Compensation generates a panel containing three QMEs in a designated medical specialty.

An unrepresented worker generally has 10 days after being furnished the panel-request form and asked to submit it to request the panel. If the worker does not act within the applicable period, the claims administrator may request the panel and select the medical specialty.

After the DWC issues the panel, the worker generally has 10 days to select a doctor from the panel, arrange the appointment, and notify the claims administrator.

If the worker does not timely select a doctor, the claims administrator may obtain the right to make the selection.

These deadlines can have significant consequences. Anyone who receives a QME notice should read the notice immediately and avoid assuming that it can be handled later.

How Is a QME Selected If You Have an Attorney?

The QME process is different when the injured worker is represented by an attorney.

For qualifying disputes involving injuries on or after January 1, 2005, the parties may use the panel QME procedure under California Labor Code section 4062.2.

Once the Division of Workers’ Compensation assigns a three-doctor panel, each side generally has the right to strike one physician from the panel within the statutory selection period. The remaining physician then becomes the panel QME.

If one side fails to exercise its strike rights on time, the other side may gain greater control over which physician from the panel performs the evaluation.

The rules governing the timing of objections, panel requests, specialties, strikes, service, and appointment scheduling can be technical. Missing a deadline may substantially affect the evaluation process.

What Is an AME?

An Agreed Medical Evaluator, or AME, is a physician selected by agreement between the injured worker’s attorney and the employer or insurance company’s attorney.

An AME is available only when the injured worker is represented by an attorney.

Unlike a panel QME, an AME does not have to be chosen from a randomly generated three-doctor state panel. The parties instead agree on a physician they are willing to use to evaluate the disputed medical issues.

An AME may also be a certified QME, but QME certification is not required simply because the doctor is serving as an AME.

The parties may consider an AME when they believe a particular physician has the appropriate expertise, experience, availability, and ability to address the medical questions presented by the case.

QME vs. AME: What Is the Difference?

Neither type of evaluator guarantees a favorable opinion.

The more important questions are whether the evaluator has the appropriate expertise, reviews the relevant evidence, understands the disputed issues, relies on accurate facts, and adequately explains the medical conclusions.

Is an AME Better Than a QME?

An AME is not automatically better than a QME.

An AME gives the attorneys the opportunity to agree on a particular physician rather than relying exclusively on the randomly generated state panel. That can be valuable when the parties know an evaluator with appropriate expertise for a complicated condition.

But agreeing to an AME is an important strategic decision.

Factors attorneys may consider include the doctor’s:

• Medical specialty
• Experience evaluating similar injuries
• Quality and thoroughness of prior reports
• Understanding of California workers’ compensation issues
• Ability to analyze causation and apportionment
• Availability for examination and follow-up
• Ability to address complicated medical histories

Once a worker undergoes an AME evaluation, the worker ordinarily cannot switch to a QME merely because the AME reaches an unfavorable conclusion.

What Records Does a QME or AME Review?

The records supplied to a medical-legal evaluator may significantly affect the resulting opinion.

Depending on the dispute, relevant information may include medical records, diagnostic imaging, treating physician reports, prior medical history, job descriptions, employment information, wage records, work restrictions, and other records relating to the injury.

The evaluator may also consider the injured worker’s account of:

• How the injury occurred
• Symptoms following the injury
• Current complaints
• Medical treatment received
• Prior injuries or medical conditions
• Regular job duties
• Time missed from work
• Current work restrictions
• Limitations on daily activities

Accuracy matters. An incomplete history, missing medical records, or incorrect description of the employee’s job can affect the evaluator’s conclusions.

Can the Insurance Company Communicate Privately With the QME?

The parties generally cannot engage in improper private or ex parte communications with a QME or AME.

California workers’ compensation law regulates what information may be sent to an evaluator and how it must be exchanged between the parties. In represented cases, information proposed for submission to a panel QME generally must first be served on the opposing party pursuant to the applicable procedures.

These rules are intended to prevent one party from secretly influencing the medical evaluator.

If you are represented by an attorney, discuss additional records or information with your attorney rather than independently sending materials to the evaluator.

What Happens During a QME or AME Examination?

During a QME or AME examination, the evaluator may ask detailed questions about the accident, your work, your medical history, your treatment, and your current limitations.

The examination may address:

• How and when the injury occurred
• Which body parts were injured
• When symptoms began
• How symptoms have changed
• Previous injuries or treatment involving the same areas
• The physical requirements of your job
• Time you have missed from work
• Current medications and treatment
• Activities that have become difficult
• Whether you believe you can return to your usual work

Depending on the specialty and disputed issues, the evaluator may conduct a physical examination, review imaging, or determine that additional diagnostic information is necessary.

The most important approach is to be accurate.

Do not exaggerate your symptoms. At the same time, do not minimize genuine limitations because you are uncomfortable discussing them. The evaluator should receive an accurate picture of both your medical history and your current condition.

How Can a QME or AME Report Affect Your Workers’ Compensation Case?

A QME or AME report can affect several major components of a workers’ compensation claim.

Work-Related Causation

A disputed claim may turn on whether employment caused or contributed to the worker’s medical condition.

For example, an insurer may argue that a back condition resulted from degeneration or a previous injury rather than a workplace accident. A medical-legal evaluator may be asked to address whether the employment caused a new injury or contributed to the current condition.

Temporary Disability

A QME or AME may address whether the worker was medically unable to perform regular employment during a particular period.

The evaluator’s opinion about work restrictions can affect disputes over temporary disability payments and return-to-work issues.

Maximum Medical Improvement

A worker is generally considered permanent and stationary or at maximum medical improvement when the medical condition has stabilized sufficiently for permanent impairment to be evaluated.

That determination can mark an important transition in the claim.

Permanent Disability

Once the condition becomes permanent and stationary, the evaluator may provide impairment findings and permanent work restrictions.

Those findings may become part of the process used to determine the worker’s permanent disability rating and benefits.

Apportionment

California workers’ compensation law may require an evaluator to determine what portion of permanent disability was caused by the industrial injury and what portion resulted from other factors.

Apportionment can substantially affect permanent disability benefits. A valid apportionment opinion should be supported by medical reasoning rather than speculation.

Future Medical Care

The evaluator may also address whether the industrial injury is reasonably expected to require future medical care.

That opinion can be particularly important when evaluating how a case should ultimately be resolved.

What If the QME or AME Report Is Wrong?

A QME or AME report should be reviewed carefully rather than accepted simply because it was prepared by a medical-legal evaluator.

Potential problems may include an incorrect accident history, missing records, an inaccurate description of job duties, incorrect information about prior injuries, failure to address an important body part, contradictory conclusions, unsupported apportionment, or inadequate medical reasoning.

For an unrepresented worker, the DWC provides a procedure for requesting correction of factual errors in a comprehensive QME report. The DWC advises that this request generally must be made within 30 days after receiving the report.

Other problems may require additional medical-legal procedures, such as obtaining a supplemental report, questioning the evaluator at a deposition, or presenting the issue to a workers’ compensation judge.

An unfavorable report does not automatically entitle either side to obtain a different evaluator.

Can a QME or AME Affect Settlement?

A QME or AME report can have a substantial effect on settlement negotiations.

For example, a report may clarify:

• Whether the injury is industrial
• Which body parts are accepted
• Whether temporary disability remains owed
• Whether the worker has permanent impairment
• The extent of permanent work restrictions
• Whether apportionment applies
• Whether future medical treatment is anticipated

Those issues can influence the value and structure of a proposed workers’ compensation settlement.

A worker should understand the medical evidence before agreeing to resolve permanent disability or future medical rights.

What If Someone Other Than Your Employer Caused the Accident?

A workplace injury can sometimes create both a workers’ compensation claim and a separate personal injury claim.

Workers’ compensation generally does not require an employee to prove employer negligence. But when someone other than the employer contributed to the accident, that third party may have separate civil liability.

For example, an employee injured in a vehicle collision while performing job duties may potentially have:

1. A workers’ compensation claim arising from the employment; and
2. A personal injury claim against the negligent driver.

Other third-party workplace cases may involve subcontractors, property owners, equipment manufacturers, maintenance companies, or other businesses.

A third-party personal injury claim may permit recovery of damages that are unavailable through workers’ compensation, including compensation for pain and suffering. Workers’ compensation reimbursement, lien, and credit rules can affect the relationship between the two cases.

Workers injured in traffic collisions can also review Anderson Franco Law’s California car accident information.

How Anderson Franco Law Helps With QME and AME Issues

A QME or AME evaluation can affect medical causation, disability, work restrictions, future care, and the overall resolution of a workers’ compensation claim.

Anderson Franco Law represents injured workers in San Francisco and throughout the Bay Area in workers’ compensation matters, including cases involving disputed medical evidence, claim denials, disability issues, and medical-legal evaluations.

The firm can help clients:

• Determine what medical issue is actually in dispute
• Review QME notices and procedural deadlines
• Evaluate QME panel options
• Consider whether an AME is appropriate
• Prepare for a medical-legal examination
• Identify important medical and employment records
• Review QME and AME reports for incomplete or inaccurate information
• Address disputed causation, permanent disability, work restrictions, and future care
• Evaluate whether a workplace accident also supports a separate third-party personal injury claim

Anderson Franco Law also focuses on direct attorney communication and coordinating workers’ compensation issues with related personal injury claims when another person or company may share responsibility for the accident.

Speak With a California Workers’ Compensation Lawyer

If you received a QME notice, a three-doctor panel, an AME proposal, or a medical-legal report you do not understand, it is important to review the situation promptly. QME procedures contain short deadlines, and missing one can affect who performs the evaluation.

Anderson Franco Law represents injured workers in San Francisco and throughout the Bay Area. Call or text (415) 727-1832 for a free consultation about a California workers’ compensation claim.