Demystifying the QME Process in California Workers’ Comp

Jun 28

Why This Doctor Visit May Decide Your Entire Case

If you’ve filed a workers’ compensation claim in California, the Qualified Medical Examiner (QME) exam may be the single most important event in your case. While technically the QME’s opinion carries no more legal weight than your primary treating physician’s, in practice, judges almost always follow the QME report—especially when it’s more detailed, more compliant with the AMA Guides, and better documented.

Whether your claim is admitted or denied, you’re entitled to a QME under the California Labor Code:

Labor Code §4060 – If your claim is denied
Labor Code §4061 / §4062 – If there are disputes over impairment, work restrictions, or care on an accepted case

But here’s the catch: facing the QME process alone—or with an attorney who won’t push back—is a huge mistake.

What Does the QME Decide?

The QME report can determine:

What body parts were injured
Your diagnoses
Whether you're entitled to temporary disability (2/3 of your wages)
If you’ve reached Maximum Medical Improvement (MMI)
Whether you have any permanent disability or work restrictions

These findings directly affect:

Your medical treatment
Your weekly benefits
Your permanent disability rating
Your final settlement

This is especially important in cumulative trauma cases—where injuries build up over time from repetitive job duties. Judges rely heavily on QME opinions to determine whether your condition is truly work-related, particularly when the symptoms involve multiple body parts or overlapping causes.

Heart Attack at Work? The QME Plays a Critical Role

Heart attacks and serious internal medical events can qualify as work injuries—but only if a QME connects the dots.

For example:
You had a heart attack while off the clock, but you’d been under intense work stress for months. The QME can evaluate the medical and occupational factors to determine whether work contributed. The right specialty—internal medicine or cardiology—is crucial here, and having an attorney who knows how to position the case is even more important.

These high-stakes cases are often denied, and it’s the QME who decides whether your case moves forward—or dies in the water.

Why Having an Attorney Changes Everything

Choosing the right specialty is everything. Orthopedic? Internal medicine? Psychology? Neurology? An experienced attorney knows which one fits your injury profile—and how to make sure you don’t get stuck with the wrong kind of doctor.

Once the specialty is picked, either side has 10 days (plus 5 for mailing) to submit the panel request. The first to act controls the process.

From there, the state medical unit sends a 3-doctor panel. You strike one, the insurance company strikes one, and the final doctor becomes your QME. But beware: some doctors are fair, others lean heavily toward the insurance companies.

At Lee Partners Law, we’ve seen these names over and over. We know who’s fair—and who will bury your claim.

Most Attorneys Are Too Scared to Push Back—We’re Not

Once the report comes in, most attorneys accept it at face value—even if it’s garbage. But we don’t.

Our team has conducted hundreds upon hundreds of cross-examinations of QME doctors. We know the AMA Guides inside and out. And we do not hesitate to challenge faulty reasoning, improper rating methodology, or missed diagnoses.

Other attorneys might be afraid to go to war with a doctor. We’re not.

If a QME ignores your stomach issues from pain meds, or downplays new symptoms like headaches, we act.
If the QME applies the AMA Guides incorrectly and lowballs your rating, we fix it.

Need a Second QME? Here’s How It Works

Every injured worker is entitled to one QME panel per claim—but if new body parts are injured or new symptoms emerge, your attorney can fight for another.

For example:

You hurt your back and started taking painkillers daily
You now have chronic stomach pain → You may need an internal medicine QME
You’ve developed headaches or memory problems → You may need a neurologist QME

We know how to argue for additional evaluations—and we don’t wait for the insurance company to agree (they almost never do).

What Happens at the QME Appointment?

Exams typically last 30–60 minutes
The QME reviews your history, listens to your symptoms, and performs physical or diagnostic tests
The doctor is supposed to be neutral—but many lean toward insurance companies

We prep you beforehand so you know what to say, how to stay consistent, and what to expect.
We also push doctors to order MRIs, EMGs, and other imaging tests—the kinds of diagnostics that often confirm what the insurance company wants to ignore.

This Process Costs You Nothing—But It Could Cost You Everything

The QME exam is completely free to you—even if your claim is denied. In fact, most judges require a QME report before approving any settlement.

That’s why it’s critical to have an attorney who knows the system, the doctors, the law, and how to fight back.

Choose a Firm That Knows the Game—and Isn’t Afraid to Play Hard

At Lee Partners Law, we’ve built a reputation on fighting smarter and harder. We don’t just "process" your QME—we strategize it, prepare you, and challenge it if it’s wrong.

With over 25 years of combined experience, our team has taken hundreds of QME cross-exams, filed countless petitions, and helped thousands of injured workers in Los Angeles and across California.