Q.M.E. PROCESS (California)

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Q.M.E. PROCESS (California)

Postby bradley on Thu Sep 17, 2009 2:35 pm

I have an accepted knee case (DOI: 04/07/09)
1.) PTP recommended surgery;
2.) U.R. and adjuster issued denial to surgery;
3.) Adjuster does not want to A.M.E. knee surgery issue
....... is my next alternative to file a Request for a Panel Q.M.E.?
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Re: Q.M.E. PROCESS (California)

Postby stewshe on Thu Sep 17, 2009 3:46 pm


The short answer is "Yes."

Another possibility is to approach the adjuster about an "Agreed Second Opinion Physician" on the sole issue of "this proposed surgery." There are many excellent physicians who hate w/c with a passion. No need to guess why! Many refuse to be a PTP just to keep dealings with adjusters to a minimum. They refuse to address anything but medical issues, i.e., not TD/PD, etc.

IMHO, many adjusters who might not agree to an AME on all issues, especially TD/PD, will agree to a limited AME over a treatment issue. Some companies have a policy of not agreeing to an AME, prefering to take their chances with PQMEs. That policy seems very short sighted to me.

These companies apparently firmly believe the only "fair" docs are what I once heard the head of the "Rating Unit" in SoCal about 20 or 30 years ago refer to as "washout artists," at a conference attended by both applicant and defense representatives. These companies have a very short list of ultra conservative docs and they spit out 3PQME requests 10 days after sending their list because they don't expect anyone to agree with them. (Yes, I know there are AAs who do the same thing.)

In the long run, I think they'd both do better by trying to agree to someone who is fair to start with, rather than going to so many QMEs. In the last couple of years I've seen several ultra conservative (and liberal) QMEs change their spots and become much more reasonable when they are the last ones left standing after 2 are struck. No wonder! They want the AME work!

If they know that "Party X" hardly ever goes to an AME, but "Party Y" usually does.....Well, let's just say if I were that doc, I'd probably be tempted to look with a bit more favor at Party Y. AME work is steadier!

Good luck!
James T. Stewart (stewshe@comcast.net)
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