AME vs. QME: Understanding Medical Evaluations in Workers' Comp

Why Medical Evaluations Matter So Much

In California workers' comp, medical evaluations determine the most critical aspects of your claim: whether your injury is work-related, what treatment you need, when you have reached maximum medical improvement (MMI), and your permanent disability rating. The evaluating doctor's report carries enormous weight with judges, insurance companies, and settlement negotiations.

When there is a dispute between you and the insurance company about any medical issue -- causation, treatment, disability level, or apportionment -- the case gets referred to either an AME or a QME under Labor Code §4060. Their report often becomes the single most influential document in your case.

What Is a QME (Qualified Medical Evaluator)?

A Qualified Medical Evaluator is a physician certified by the California Division of Workers' Compensation (DWC) Medical Unit to perform independent medical evaluations. QMEs are used when the injured worker does not have an attorney, or when the parties cannot agree on an AME.

The QME Selection Process

The QME process is governed by Labor Code §4062 and works differently depending on whether you have an attorney:

If You Do NOT Have an Attorney (Unrepresented)

• Either you or the insurance company can request a QME panel from the DWC Medical Unit
• The DWC issues a panel of three QMEs in the relevant medical specialty
• You have the right to choose which of the three doctors you see
• You must select within 10 days or the insurance company can select for you
• The QME's report is presumed correct and carries significant weight

If You Have an Attorney (Represented)

• The parties first attempt to agree on an AME (see below)
• If they cannot agree within a specified time, either party requests a QME panel
• A panel of three QMEs is issued
• Each side can strike one name, and the remaining doctor conducts the evaluation
• The QME's report can be challenged more effectively with legal representation

What Is an AME (Agreed Medical Examiner)?

An Agreed Medical Examiner is a physician that both you (through your attorney) and the insurance company agree upon to conduct the medical evaluation. AMEs are only available when you have legal representation.

The AME Selection Process

• Your attorney and the insurance company's attorney negotiate to select a mutually acceptable physician
• Both sides research the doctor's history, report quality, and tendencies
• If the parties agree, that doctor becomes the AME
• If they cannot agree, the case defaults to the QME panel process

Why AMEs Are Often Preferable

There are several advantages to the AME process:

• Your attorney has input: Unlike the random QME panel, your attorney helps select the AME based on the doctor's history and expertise
• Stronger presumption: An AME's report carries even greater weight than a QME's because both parties agreed to the evaluator
• Specialization: Your attorney can push for a specialist in the exact area of your injury
• Known quantities: Experienced attorneys know which doctors provide thorough, fair evaluations

AME vs. QME: Side-by-Side Comparison

What Happens During the Medical Evaluation

Whether you see an AME or QME, the evaluation process is similar:

Before the Appointment

• The evaluating doctor receives your complete medical records, including all treating physician reports
• They review the claims administrator's documentation
• Your attorney (if you have one) may submit a cover letter highlighting key medical issues
• The appointment is typically scheduled 2-4 weeks after selection

During the Evaluation

• History taking: The doctor will ask detailed questions about your injury, symptoms, treatment history, work duties, and medical history
• Physical examination: A thorough exam of the injured body parts, including range of motion tests, strength tests, and neurological assessments
• Review of records: The doctor discusses findings from your medical records and imaging studies
• Duration: Evaluations typically last 1-3 hours depending on complexity

The Report

After the evaluation, the doctor prepares a comprehensive written report addressing:

• Whether your injury is work-related (causation)
• What body parts are affected
• Whether you have reached maximum medical improvement
• Your permanent disability rating under the AMA Guides (5th Edition)
• Apportionment -- how much of your disability is due to work versus other factors (Labor Code §4663)
• Future medical care recommendations
• Work restrictions and limitations

How to Prepare for Your Medical Evaluation

Your performance during the evaluation directly impacts the report, which directly impacts your settlement. Here is how to prepare:

Before the Appointment

• Review your medical records. Know your treatment history, surgeries, medications, and diagnostic results.
• Prepare a symptom diary. Bring notes describing your daily pain levels, limitations, and how the injury affects your life.
• List all body parts affected. Do not forget to mention secondary symptoms like sleep disruption, depression, or radiating pain.
• Know your work history. Be prepared to describe your job duties in detail, including physical demands.
• Review with your attorney. Your lawyer can coach you on what to expect and how to communicate effectively.

During the Appointment

• Be honest. Exaggeration will be detected and destroys your credibility. Inconsistencies between your statements and medical records undermine the entire report.
• Describe your worst days, not your best. When asked about pain and limitations, describe the full range of your experience, emphasizing how the injury impacts you on bad days.
• Do not minimize. Many workers downplay symptoms out of habit. If something hurts during the physical exam, say so clearly.
• Be thorough. Mention every affected body part, every limitation, and every way the injury impacts your daily life. Doctors cannot evaluate what they do not know about.
• Do not volunteer information about prior injuries unless directly asked. Answer questions honestly but do not offer details that were not requested.

Challenging an Unfavorable Report

Sometimes the AME or QME report comes back with findings that significantly undervalue your injury. This can happen because of incomplete information, doctor bias, or legitimate medical disagreement. Here is what you can do:

For QME Reports

• Supplemental report request: Your attorney can submit additional medical evidence and request the QME issue a supplemental report addressing the new information
• Deposition: Your attorney can depose the QME under oath, challenging their findings, methodology, and conclusions
• Cross-examination at trial: If the case goes to hearing, the QME can be cross-examined about inconsistencies or errors in their report
• Rebuttal evidence: Your treating physician's opinion, additional medical records, or expert testimony can be used to rebut the QME's findings

For AME Reports

Challenging AME reports is harder because both parties agreed to the evaluator. However, options include:

• Supplemental questions: Either party can submit additional questions for the AME to address
• Showing substantial evidence: If the AME report is not supported by substantial medical evidence, it can be challenged
• Procedural errors: If the AME did not review all relevant records or made factual errors, the report may be questioned
• New evidence: If your condition changes after the AME report, new medical evidence can be introduced

When to Challenge

Not every unfavorable report should be challenged. Your attorney will analyze the report and determine whether:

• The findings are clearly inconsistent with your medical records
• The doctor overlooked important symptoms or body parts
• Apportionment analysis is flawed or unsupported
• The disability rating uses incorrect impairment factors
• The doctor failed to follow the AMA Guides methodology

The Impact on Your Settlement

The medical evaluation report directly drives your settlement value. Here is how:

• Permanent disability rating: The evaluator assigns an impairment rating that converts to a permanent disability percentage. Under Labor Code §4660, this percentage determines your permanent disability benefits.
• Future medical care: The evaluator's recommendations for ongoing treatment determine what medical care the insurer must authorize.
• Apportionment: Under Labor Code §4663 and Labor Code §4664, the evaluator determines how much of your disability is work-related versus pre-existing or non-industrial -- directly reducing or increasing your settlement.
• Work restrictions: The evaluator's opinion on your functional limitations affects whether you qualify for supplemental job displacement benefits (DIR Supplemental Job Displacement Benefit).

Common Mistakes During Medical Evaluations

Even well-prepared injured workers make errors during their AME or QME evaluation that can significantly reduce their disability rating and settlement value. Here are the most common mistakes to avoid:

Inconsistency Between Statements and Records

The evaluating doctor compares everything you say to your medical records. If you tell the evaluator you have never had back pain, but your medical records show a chiropractic visit five years ago, this inconsistency undermines your credibility on everything else in the report. Always be truthful -- if you are unsure about something, say "I do not recall" rather than guessing.

Minimizing Symptoms During the Exam

Many injured workers instinctively try to appear strong during the physical examination. They push through pain, extend further than comfortable, and underreport their limitations. The doctor takes these findings at face value. If it hurts, say so. If you cannot do something, say so. The evaluation is not a performance -- it is a medical assessment.

Forgetting to Mention All Affected Body Parts

A fall that primarily injured your back may also have caused shoulder pain, headaches, sleep disruption, or depression. If you do not mention these secondary effects, they will not appear in the report, and you cannot receive compensation for them. Before the evaluation, make a written list of every body part and symptom affected by your injury.

Not Describing Functional Limitations

Do not just describe pain -- describe what the pain prevents you from doing. "My back hurts" is less impactful than "I cannot sit for more than 20 minutes, I cannot lift more than 10 pounds, I wake up three times a night due to pain, and I can no longer play with my children on the floor." Functional limitations drive the disability rating.

Volunteering Unrelated Medical History

Answer questions about your medical history honestly, but do not volunteer information that was not asked. If the doctor asks about prior injuries to the injured body part, answer truthfully. But do not launch into your entire medical history or discuss conditions unrelated to the claim.

The Role of Your Treating Physician

Your Primary Treating Physician (PTP) plays a crucial role alongside the AME or QME process:

• Treatment authority: Your PTP controls your medical treatment, not the evaluator. The AME/QME provides opinions, but your PTP manages your care.
• Medical records: Your PTP's detailed treatment notes are reviewed by the evaluator. Thorough, well-documented records from your PTP strengthen the evaluation.
• Supplemental opinions: If the evaluator reaches unfavorable conclusions, your PTP's opinions can be used as supporting or rebuttal evidence.
• Ongoing documentation: Your PTP continues documenting your condition even after the evaluation, which matters if your condition changes.

It is essential that you communicate openly with your treating physician about all symptoms and limitations. Every visit is an opportunity to build your medical record, which the evaluator will rely upon.

Frequently Asked Questions

Timeline: What to Expect in the Evaluation Process

Understanding the typical timeline helps you plan and reduces anxiety about the process:

The process can take 3-6 months or longer depending on complexity, scheduling availability, and whether challenges or supplemental reports are needed. Your attorney manages this timeline and keeps you informed at each stage.