Why is your workers’ compensation claim delayed?

When you claim workers’ compensation benefits, you and your employer may disagree about appropriate treatment options or the extent to which your injury resulted from the job. The California Division of Workers’ Compensation has a process for resolving such disputes, but the state auditor has faulted DWC for significant deficiencies in this process. 

A report issued by the auditor highlights problems with “Qualified Medical Evaluators” as a key factor that may delay your workers’ compensation claim. 

What is a “Qualified Medical Evaluator”? 

A QME is a physician who may examine you in response to a workers’ compensation disagreement between you and your employer. This doctor will evaluate your physical condition, ability to go back to work, future medical needs and right to receive workers’ compensation benefits. You may select a QME from a panel, and if that person is not available within 60 days, you or your employer can request a new QME or panel. 

How do QME problems delay your workers’ compensation claim? 

Doctor shortages often result in the need to repeat requests for new QMEs or panels, and this process may delay benefits and treatment. The auditor outlines how DWC’s failures have contributed to these shortages: 

• There is not an adequate plan to recruit enough doctors to serve as QMEs. 
• Pay is low, as QME billing rates have not changed since 2006. 
• DWC lacks a system for investigating complaints against QMEs and has penalized doctors for alleged overbilling by withholding reappointment. 

Also, DWC does not have good procedures for evaluating QME reports, resulting in low-quality reports that can affect how quickly you receive your benefits. 

It is important that you understand how these deficiencies in the workers’ compensation system may delay your ability to get prompt medical benefits and treatment for a job-related injury.