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Kamin: The Importance of QMEs Early in Claims

  • State: California
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Getting the right specialty of qualified medical evaluators in cumulative trauma claims is an important tool to successfully defend against them, and there are several things that claims departments can do to help get the correct QME on a case.

John P. Kamin

John P. Kamin

Early on in a claim, it's important for adjusters to grant authority to the defense attorney to get a QME in the correct specialty.

For example, if the case features an injury to a joint, an orthopedic surgeon (MOS) is going to be the best specialty. (I recall multiple doctor depositions where a surgeon incredulously asks why an applicant who needs knee surgery has been treated by a chiropractor, who is incapable of performing the knee surgery and has shown minimal interest in actually helping the applicant.)

If the defense attorney has the authority to go get the QME in orthopedic surgery early on a claim involving a knee injury, the case is going to proceed toward a more expeditious resolution. To achieve that goal, the claims adjuster should provide clear authority to get the QME and directly contact the defense attorney to alert him or her to any/all delay and denial letters early in the case.

The reason for the second criterion is that parties can use delay and denial letters to obtain QME panels. While that sounds simple enough, sometimes clients send the delay/denial to the applicant’s attorney, but not to the defense attorney. In that case, you cannot get a QME panel without that letter in denied cases.

Other times, clients send the delay/denial letters to the defense attorney but in a slower way than how they sent it to the applicant’s attorney. Doing this gives the applicant’s attorney more time to get the QME panel than the defense attorney.

With that in mind, it’s important for adjusters to keep in close contact with the defense attorney during the decision time frame.

But wait, QMEs are costly

All QMEs do indeed cost a good amount of money. However, a QME in the wrong specialty can cost a defendant even more money in unnecessary diagnostics, incorrect diagnoses, exaggerated PD, excessive temporary total disability and erroneous future medical care recommendations.

What about threshold issues?

In cases with a threshold dispute, such as employment or coverage, it’s still important to get QMEs in the right specialty. That way, should the defense fail, the defense isn’t stuck with a QME in the wrong specialty.

Some may wonder: Doesn’t this mean that the exam will occur at/before the threshold issue is being decided? No, not necessarily; one can obtain the QME panel and postpone the initial evaluation until the threshold dispute is resolved. Then at least the correct QME specialty is waiting in the wings, should the threshold issue go against the defendant.

A smaller subset of cases could be aided by proceeding to the QME while the threshold issue is being litigated, as some claims have a seemingly healthy applicant but a complex threshold employment issue that could take years to resolve.

In those cases, it would behoove the parties to know if indeed it is a low-value case. If the QME comes back with a low-value report, at least the parties would know that and could settle without years of costly litigation. And if it’s a high-value case, at least the parties would know that their litigation is worthwhile and understand the stakes they are litigating for.

Conclusion

It’s important for adjusters to give authority to obtain QME panels in the right specialty and to get their delay/denial letters to the defense attorney in the most efficient manner. Doing so will save large sums of money in the long run.

John P. Kamin is a workers’ compensation defense attorney and partner at Bradford & Barthel’s Woodland Hills location. He is WorkCompCentral's former legal editor. This entry from Bradford & Barthel's blog appears with permission.

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