Getting the right specialty of qualified medical evaluator on cumulative trauma claims is an important tool to successfully defending against them, and there are several things that claims departments can do to help get the correct type of qualified medical evaluator on a claim.
Early on in a claim, its important for adjusters to grant authority for the defense attorney to get a QME in the correct specialty.
For example, if the case features an injury to a joint, then an orthopedic surgeon (MOS) is going to be the best specialty. (The undersigned recalls multiple doctor depositions where a surgeon incredulously asks why an applicant who needs a knee surgery has been treated by a chiropractor, who is incapable of performing the knee surgery and has shown minimal interest in actually helping the applicant.)
If the defense attorney has authority to go get the QME in orthopedic surgery early on a claim involving a knee injury, then the case is going to proceed toward a more expeditious resolution. In order to achieve that goal, the claims adjuster should provide:
- Clear authority to get the QME
- Directly contacting the defense attorney to alert them to any/all delay and denial letters early in the case
The reason for the second criteria is that parties can use delay and denial letters to obtain QME panels. While that sounds simple enough, sometimes clients send the delay/denial to applicant’s attorney, but not to defense attorney. In that case, the undersigned cannot get a QME panel without that letter in denied cases.
Other times, clients send the delay/denial letters to the defense attorney, but send it in a slower way than they sent it to the applicant’s attorney. Doing this gives the applicant’s attorney more time to get the QME panel than the defense attorney.
With that in mind, it’s important for adjusters to keep in close contact with the defense attorney during the decision timeframe.
BUT WAIT, QMES ARE COSTLY
All QMEs do indeed cost a good amount of money. However, a QME in the wrong specialty can cost a defendant even more money in unnecessary diagnostics, incorrect diagnoses, exaggerated PD, excessive temporary total disability, and erroneous future medical care recommendations.
BUT WHAT ABOUT THRESHOLD ISSUES
On cases with a threshold dispute, such as employment or coverage – it’s still important to get QMEs in the right specialty. That way, should the defense fail, the defense isn’t stuck with a QME in the wrong specialty.
Some may wonder – doesn’t this mean that the exam will occur at/before the threshold issue is being decided? No, not necessarily – one can obtain the QME panel and postpone the initial evaluation until the threshold dispute is resolved. Then at least the correct QME specialty is waiting in the wings should the threshold issue go against the defendant.
A smaller subset of cases could be aided by proceeding to the QME while the threshold issue is being litigated, as some claims have a) an applicant who seems to be healthy but b) a complex threshold employment issue that could take years to resolve.
In those cases, it would behoove the parties to know if indeed it is a low-value case – because if the QME comes back with a low value report, at least the parties would know that and could settle the claim without years of costly litigation. And if it’s a high-value case, well at least the parties would know that their litigation is worthwhile and the stakes they are litigating for.
CONCLUSION
In conclusion, it’s important for adjusters to give authority to obtain QME panels in the right specialty and to get their delay/denial letters to the defense attorney in the most efficient manner. Doing so will save them large sums of money in the long run.
Got a question about workers’ compensation defense issues? Feel free to contact John P. Kamin. Mr. Kamin is a workers’ compensation defense attorney and partner at Bradford & Barthel’s Woodland Hills location, where he monitors the recent legislative affairs as the firm’s Director of the Editorial Board. Mr. Kamin previously worked as a journalist for WorkCompCentral, where he reported on work-related injuries in all 50 states. Please feel free to contact John at jkamin@bradfordbarthel.com or at (818) 654-0411.
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