REPORT: QME Shortage Delaying Claims; Division of Workers’ CompensationFailed to Adequately Administer QME Process

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If you’re wondering why you can’t get a timely qualified medical evaluator or a timely replacement panel for unavailable doctors, or wire claim got denied because of the QME problem this should explain it for you. If you have any questions about the qualified medical evaluator process QME, contact our office right away as there are several time limitations that may apply to you.

A lack of available medical evaluators resulted in the automatic denial of claims some state workers filed, delaying benefits by an average of four months, according to a new report by California state Auditors. a lack of available QMEs — an issue Howle highlighted in a separate report published Tuesday — delayed decisions on compensability and slowed return to work, according to the new audit. The review found that a lack of available medical evaluators has at times delayed appointments for medical evaluations, resulting in denied claims and some injured employees’ having to wait to receive benefits,

State Auditor Elaine Howle on Tuesday published a report saying the Division of Workers’ Compensation hasn’t adequately administered the qualified medical evaluator process. Howle said the division hadn’t taken the necessary steps to ensure there are enough QMEs to meet demand or that they are writing quality reports. She also said the division inappropriately used the reappointment process to discipline some QMEs.

Diane Worley, director of policy implementation for the California Applicants’ Attorneys Association, said she thinks issues with the QME process are worse than what is reflected in the auditor’s report.

“The report focuses on the gross number of QMEs currently available being inadequate, due to failure of recruitment and retention and actions by the DWC to drive QMEs out of the system (inadequate fee schedule and unjustified disciplinary action) — all of which is true — but it fails to address the significant problem of lack of physicians within certain specialties and geographic availability,” she said.

Worley said recommendations for setting timelines for the DWC to act could have little to no effect because the division has been late on several obligations. The division hasn’t adopted the home health care and interpreter fee schedules mandated by Senate Bill 863. And, while part of the reforms in Senate Bill 899 required the division to update the Permanent Disability Rating Schedule at least once every five years, the 2005 schedule remained in effect until SB 863 was enacted in 2012.

“There has to be more oversight and accountability in the QME process from outside the DWC to improve this long-standing problem,” she said.