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kealohiwc · 11-29-2008, 06:16 PM

I am the "new kid" on this discussion forum. Who can tell me about AME's and QME's? I was injured on February 16, 2005 with a settlement in the future. I am on SSDI within the state of California and receiving monthly compensation, but the WC insurance company is making my life miserable. Who has gone through this stressful situation and questioning their quality of life experiencing the WC beauracratic tape?

jayne · 11-29-2008, 06:30 PM

chris chris and Monster is from california so they will be along soon... 1171 is an adjuster and she will be along shortly

1171 · (This post was last modified: 11-29-2008 06:57 PM by 1171.)

you can find a lot of information on california comp system and particularly the QME process here:
http://www.dir.ca.gov/dwc/MedicalUnit/QME_page.html.
It's been over 25 years since I was an adjuster but i'm glad to share whatever information I have.

chrischris · 11-29-2008, 09:05 PM

Consider it like a game of checkers. Relax and don't stress out while you're awaiting defense to make their next move. Once they do, then it's your turn. If you have an attorney it is basically the same game except that you are not informed along the way.

To answer your question, if there is a dispute about something in your claim the insurance carrier will pay for a med/legal appt. This doctor is very important to your case. S/he will determine compensability, disability, apportionment, future medical and make comments about you in a med/legal report. This report is supposed to be the accepted solution to either negate your claim, or start the settlement process. It's supposed to work that way, but the Claims Examiner still has the right to ask for a "supplemental" report which is another 60 days. Delays are also part of the game. The I/C tries to starve out the I/W as long as they can so the I/W will be "anxious" to settle at any price.

AME = Agreed Medical Examiner
You only have an AME if you are repped. The doctor is chosen by your attorney and the defense attorney. Names of various doctors go back and forth between defense and A/A, until one can be "Agreed upon. Thus, Agreed Medical Examiner. An appt. is made, all your records go to the AME, and defense notifies you of the date and time of AME appt. Most AME's in California are 7-14 months out. Another delay, and defense is not in a hurry.

QME = Qualified Medical Examiner
If you are unrepped, you request a QME of the "medical speciality" of your choice. The DWC medical unit will send you a random list of 3 QME doctors which you get to make the choice.

I hope this helps a little.

I'm only two year's into the system, have had 1 QME, and 2 AME's so far, and awaiting at least 2 more AME's. I am working full time, with restrictions, and receiving estimated permanent disability payments on a biweekly basis. If I wasn't working, there is no way I could live on the PD amount.

Good luck to you.

kealohiwc · 11-30-2008, 03:35 PM

Your information has been extremely helpful. Although, you stated, "I am working full time, with restrictions, and receiving estimated permanent disability payments on a biweekly basis. If I wasn't working, there is no way I could live on the PD amount." My doctor won't release me and seeing him once a month...pain management. What did you do to receive biweekly disability payments and work full time...other than apply for the job and got hired? What do you mean by "estimated permanent disability payments"?

I am no longer receiving WC benefits, but have been awarded SSDI through the state of California. How does SSDI affect my settlement? If I were to work, does it jeopardize the settlement? I am unable to sit, stand, walk longer than fifteen minutes at a time. My medication makes me nauseous, groggy, cannot focus, and lack concentration. I try to relax and not stress, but it is soooooooooo difficult.

Thank you for your words of wisdom!

chrischris Wrote:Consider it like a game of checkers. Relax and don't stress out while you're awaiting defense to make their next move. Once they do, then it's your turn. If you have an attorney it is basically the same game except that you are not informed along the way.

To answer your question, if there is a dispute about something in your claim the insurance carrier will pay for a med/legal appt. This doctor is very important to your case. S/he will determine compensability, disability, apportionment, future medical and make comments about you in a med/legal report. This report is supposed to be the accepted solution to either negate your claim, or start the settlement process. It's supposed to work that way, but the Claims Examiner still has the right to ask for a "supplemental" report which is another 60 days. Delays are also part of the game. The I/C tries to starve out the I/W as long as they can so the I/W will be "anxious" to settle at any price.

AME = Agreed Medical Examiner
You only have an AME if you are repped. The doctor is chosen by your attorney and the defense attorney. Names of various doctors go back and forth between defense and A/A, until one can be "Agreed upon. Thus, Agreed Medical Examiner. An appt. is made, all your records go to the AME, and defense notifies you of the date and time of AME appt. Most AME's in California are 7-14 months out. Another delay, and defense is not in a hurry.

QME = Qualified Medical Examiner
If you are unrepped, you request a QME of the "medical speciality" of your choice. The DWC medical unit will send you a random list of 3 QME doctors which you get to make the choice.

I hope this helps a little.

I'm only two year's into the system, have had 1 QME, and 2 AME's so far, and awaiting at least 2 more AME's. I am working full time, with restrictions, and receiving estimated permanent disability payments on a biweekly basis. If I wasn't working, there is no way I could live on the PD amount.

Good luck to you.

chrischris · 11-30-2008, 08:51 PM

Once your temporary disability payments stop because either you have been released back to work and you have restrictions, or TD ends because of the 104 week limit in California, the I/C has to immediately start paying you estimated permanent disability, based on what your Primary Treating Physician has reported about your injury. A final rating can't be done until my spine surgeon releases me at MMI (maximum medical improvement), which will be in February I hope, and then I will be sent to an ortho AME for a rating.

I hope by that time, we can have a settlement hearing and end all of this. I have permanent disability, but I have a job that works with me; for the most part anyway. I just want to work, do my job, and have my x-employer and WC out of my life and leave me alone!

My case is a very complicated one, and I can't explain it all just right now. Actually, every case is different and no two injured workers will be treated alike. Some C/A's are ok, some NCM's are ok, some WC docs are ok. When you fall into the hands of one from the dark side, your life is a living hell.

Take care!