QME Report Filing Under DWC Scrutiny

Per a recent report on the California Society of Industrial Medicine and Surgery (CSIMS) website, the Division of Workers’ Compensation (DWC) is taking new measures to enforce timely filing deadlines for medical-legal reports. Though the extent of any potential penalties remains ambiguous, CSIMS writes that the DWC Medical Unit has issued warnings to qualified and agreed medical evaluators (QMEs and AMEs) of “possible enforcement actions” should they fail to “serve medical-legal reports in a timely manner.”^[1]

Frequently Asked Questions:

Q: How long do QMEs and AMEs have to file their reports from the date of the evaluation procedure?

A: California Labor Code § 139.2(j)(1)(A) is abundantly clear on this point, stating that “the timeframe for initial medical evaluations to be prepared and submitted shall be no more than 30 days after the evaluator has seen the employee or otherwise commenced the medical evaluation procedure.”^[2] This timeline is backed up by California Code of Regulations § 38, which adds that any supplemental reports must be filed within 60 days of the medical-legal procedure.^[3]

Q: Are there any circumstances that allow for an extension of this timeline?

A: Yes, but they are vanishingly narrow. To be granted an extension, a QME or AME must fill out a special DWC form, which allows for extensions for additional medical tests or consultations and the umbrella category of “good cause.” Though this sounds broad, it is actually very stringent – per the DWC, medical emergency, bereavement, or natural disaster are the only circumstances that meet the criteria of “good cause.”

Q: When is the QME Extension Form 112 due?
A: The extension form is due to the DWC, injured worker, and insurance carrier no later than 5 days before the ordinary filing deadline. In the case of good cause, the filing deadline may be extended by up to 15 days. The extension widens to 30 days in the case of medical tests or consultations.

Explanation

Any failure to meet the deadlines described above is considered non-compliant behavior and is subject to DWC sanctions, including the loss of QME or AME status.

To use a baseball analogy, make sure you don’t strike out. Per California Code of Regulations § 51, “[t]he Administrative Director may deny reappointment to any QME who has failed to comply with the evaluation time frames in sections 34 and 38 on at least three occasions during the calendar year.”^[4]

Many medical-legal evaluators – particularly those with busy schedules – struggle to meet their filing deadlines. As the DWC begins to crack down on tardiness across the entire workers’ comp spectrum, we strongly encourage evaluators to examine their reporting and billing practices. We’ll be the first to acknowledge that the tangle of paperwork and deadlines can be a lot to keep track of. But it’s equally important to note that timely filing is of critical importance – to your practice, to an injured worker, and to the entire workers’ comp system.