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Department of Industrial Relations
Its Failure to Adequately Administer the Qualified Medical Evaluator Process May Delay Injured Workers’ Access to Benefits

Report Number: 2019-102

Figure 1
DWC Oversees QMEs

A chart describing the various responsibilities of the DWC’s oversight of QMEs, including appointing, reappointing, and disciplining QMEs, as well as investigating complaints. When appointing QMEs, DWC evaluates physician’s eligibility to participate in the program, administers the QME exam, ensures that applicants have paid applicable fees, and appoints QMEs for 2-year terms. During the QME reappointment process, DWC accepts applications and fees, verifies that QMEs have complied with specific requirements, and reappoints QMEs for 2-year terms. DWC also accepts, investigates, and reviews complaints against QMEs. It may also review billing for medical-legal reports and determine violations of the department’s regulations. Based on the result of investigating the complaints, DWC administer discipline based on sanction guidelines in state regulations.

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Figure 2
Injured Workers and Their Employers Use the QME Selection Process to Resolve Certain Disputes

A flowchart describing the QME selection process the injured workers and their employers use to resolve certain disputes. After an injured worker files the workers’ compensation claim, the injured worker may be reimbursed up to $10,000 for treatment until the claim is accepted or denied. If claim is accepted, the worker can obtain medical treatment from employers, and if claim is denied, from another source. If a dispute arises between the injured worker and the employer on issues such as whether the injury occurred on the job or the existence/extent of injury sustained, the injured worker then has to go through the QME process. The QME process starts when the injured worker or the employer requests a QME. DWC then generates a panel, or list, of three QMEs. If the injured worker is unrepresented, generally he or she selects a QME and makes an appointment within 10 days. If the injured worker is represented, the worker eliminates one QME while the employer eliminates another QME, and the injured worker generally makes an appointment with the remaining QME within 10 days. However, if the selected QME is not available within 60 days, the injured worker or employer can generally request a replacement QME or a replacement panel. The QME who is eventually selected reviews records and examines the injured worker, and within 30 days of the evaluation, writes and distributes the medical-legal report. The injured worker and employer may use the medical-legal report to resolve the dispute, or meet before a workers’ compensation judge to resolve the dispute. After the QME process, the injured worker receives the benefits if entitled.

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Figure 3
As Requests for QME Services Increased, the Number of QMEs Decreased
Fiscal Years 2013–14 Through 2017–18

Two charts showing that from fiscal year 2013-14 to 2017-18, as requests for QME services increased, the number of QMEs decreased. The chart for QME panel requests show a generally increasing trend from 105,732 in fiscal year 2013-14 to 145,093 in fiscal year 2017-18, a 37 percent increase. On the other hand, the chart for number of QMEs show a decreasing trend from 3,157 in fiscal year 2013-14 to 2,782 in fiscal year 2017-18, a 12 percent decrease.

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Figure 4
The Number of Replacement Panels Is Increasing Because QMEs Are Not Available

A bar chart describing the increasing trend in the number of replacement panels because QMEs are not available. The chart contains two bars for each year—one set of bars for the total number of replacement panels and the second set of bars showing the replacement panels because a QME is not available within 60 days. From fiscal years 2013-14 to 2017-18, the number of total replacement panels increased from 23,648 to 44,569. From fiscal years 2013-14 to 2017-18, the number of replacement panels because of unavailable QMEs quadrupled from 4,573 to 18,929.

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Figure 5
DWC Used the Reappointment Process to Discipline QMEs, a Practice We Find Inappropriate

A flowchart describing DWC’s investigation and disciplinary process as well as its reappointment denial process, and how DWC inappropriately used the reappointment process to discipline QMEs. On the left side of the flow chart, we describe the investigation and disciplinary process. On the right side of the flowchart, we describe the separate reappointment denial process. The chart shows that instead of following through with the investigations and disciplinary process, DWC jumps to using the reappointment denial process. After DWC denies a QME’s reappointment, the individual cannot legally provide QME evaluations or earn related income. To first describe the investigation and disciplinary process: when DWC’s investigations section receives complaints against a QME, it gathers evidence on violations of the department’s regulations. According to the department’s regulations, the next step involves its medical director forwarding the identified evidence of violations to its administrative director, and if the latter sustains the case, DWC should issue an accusation to the QME specifying alleged violation of regulations. The accusation notifies the QME of his or her right to a hearing. DWC should then assign the case to a hearing officer or administrative law judge who hears the cases and may propose discipline. DWC’s administrative director then makes the final decision on disciplinary action. However, instead of following the appropriate steps, after gathering evidence of as violation, DWC used the reappointment denial process for discipline. To describe the whole reappointment denial process on the right side of the flowchart, the reappointment denial process usually begins with QME submitting a reappointment application with supporting documents and appropriate fess. DWC may deny the QME’s reappointment if the QME was not in compliance with all applicable regulations and guidelines. DWC must notify the QME in writing of the reappointment denial and the reason of denial. After the notice of reappointment denial, the QME has 30 days to appeal, and DWC has 60 days from receipt of appeal to notify the QME of its decision to grant the appeal or uphold the denial. If DWC upholds the denial, it issues a statement of issues specifying which regulations the QME has not complied with and notifies the QME of his or her right to a hearing. If the QME requests a hearing within 15 days, DWC assigns the case to a hearing officer or administrative law judge, who hears the case and proposes a determination regarding the QME’s reappointment. DWC’s administrative director then makes the final decision on whether to reappoint the QME.

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