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Posted on: Jan 21, 2020

The State Auditor's report exposing the Department of Industrial Relations failure to adequately administer the Qualified Medical Evaluator (QME) process continues to ripple throughout the workers' compensation community, and while the report rightfully characterizes the decline in QMEs as a long-standing problem causing delays in injured workers' ability to access benefits, there are other key components compounding the QME crisis: specifically the lack of certain specialty QMEs needed to evaluate some of the most catastrophic injuries in the system.

The Joint Legislative Audit Committee held an oversight hearing on January 7 to review the findings of the auditor's report and testimony was given on behalf of CAAA that the failure to recruit and retain certain QME specialties is exacerbating the issue. 

For example, the DWC completely eliminated the QME specialty of neuropsychology from the QME panels in 2015 - the specialty most frequently requested on traumatic brain injury cases. The DWC subsequently opposed a bill, which passed with bipartisan support, to reinstate the neuropsychology specialty. This opposition resulted in the bill's veto from former Governor Jerry Brown. 

Additionally, there are several specialties such as oncology and infectious diseases for which there are not enough doctors for a panel to issue.

The lack of specialist QMEs has resulted in injured workers having to travel hundreds of miles to be seen as there are no doctors available on the list in their area, injured workers not even being able to get an evaluation with an appropriate specialist to evaluate some of the most serious and catastrophic injuries.

A pertinent story from one of our members showcases a typical delay in the QME process:

A 40-year-old male machine operator employed for 3 years starts noticing pain and numbness in his hands and wrists in October 2018 and files a claim.  

The occupational medicine treating doctor diagnoses carpal tunnel syndrome and finds industrial causation, but the carrier denies the claim and wants a QME evaluation. 

The worker gets an attorney.

The first QME panel issues but the doctor selected isn't setting until seven months later. Carrier objects and requests a replacement panel.

The second panel issues but that doctor isn't scheduling until over three months from the request date.

The carrier objects and requests another panel, but the doctor from the third panel is no longer doing evaluations at the address listed on the panel, so he won't schedule the evaluation and the carrier has to request a fourth panel.

The fourth panel issues (it is now nine months after the claim was filed) and the remaining doctor is setting beyond 90 days, but the carrier has now agreed to waive the 90-day deadline for an evaluation date because they've simply given up.

The evaluation is set for November 2019, one month later than the QME evaluation from the first panel would have been set.

In the meantime, the injured worker has been off of work since October 2018, burned through a year of state disability insurance, and has obtained carpel tunnel surgery through his private group health insurance along with other treatments such as physical therapy.

The Injured worker goes back to work in December 2019 - one month after the carpal tunnel surgery - yet he is still waiting for the report from the QME evaluation over a year after the process began. 

How does any of this make sense?

To view the full hearing and to hear testimony from CAAA's Director of Policy Implementation Diane Worley, click here (CAAA's testimony begins at the 2:14:57 mark).

To read how the system has failed others, check out an article from CalMatters here.