Am I about to be thrown under the bus? Req for QME...

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Latest post Fri, Dec 14 2007 5:19 PM by mchmjh. 5 replies.
  • Wed, Dec 12 2007 2:35 PM

    • mchmjh
    • Not Ranked
    • Joined on Wed, Dec 12 2007
    • Posts 19

    Question [=?] Am I about to be thrown under the bus? Req for QME...

    I'm new to the Board, so please bear with my "story" and questions. Any guidance would be greatly appreciated :)

    DOI: Feb. ' 06 (yes, I worked almost a year injured before filing a WC claim trying to resolve through my chiro and PT through my own insurance with no resolution - that's loyalty for ya!)

    WC claim filed: 10-13-06
    TTD since 1-8-07
    37 y/o - secty

    Current diagnosis: Right CTS; cervical sprain; cumulative/overuse/repetitve of my right upper extremity areas (neck, shoulder, trapizus, scapula)

    T'ment to date:
    Various Pain meds since claim filed

    Mar. '07: addition of a TENS unit

    Mar. '07 - Aug. '07: IC sporadically approved 22 PT sessions, and continuance of pain meds

    Sept. '07: PTP referred me to a Pain Mgmt Dr.

    Oct. & Nov. '07: 2 sessions of injections (TPI & nerve block)

    Newest Development:
    This past week I received from my IC a request for a QME (and I have signed and mailed it in per its instructions). In the letter the IC states they're "objecting to my PTP's most recent report, more specifically they're objecting to my level of permanent disability, duration of TTD and/or the extent & scope of medical treatment."

    My PTP office stated to me that the doctor's report is one page and simply states: I'm TTD; to follow up with PTP at my 12/24/07 appt; and continue with the pain management doctor I've been treating with.

    I called my CA and asked specifically what they're disputing because my PTP is simply agreeing with my pain mgmnt dr who is requesting another session of injections (TPI & nerve block).

    The CA literally stated to me that she feels my PTP doesn't know what he's doing; is relying to heavily on the pain mgmt doctor; and doesn't feel my PTP really has a t'mnt plan for me - - therefore, they're requesting a QME to resolve the dispute.

    Here are my questions/concerns:

    1. Am I going to get a "fair deal" from a QME? I have an uncanny feeling that while supposedly a QME is supposed to be unbiased, the doctor is going to do whatever will please the IC.

    2. Does a QME truly take several months to book, attend and get a report? Because I've been TTD for almost a year already and from the message board it appears I'm going to have a problem with "disability income"? i.e., this whole confusing thing about EDD/SSDI and not qualifying because I've been TTD for so long...

    3. Does a QME's report trump what my PTP feels my t'mnt should be and/or my diagnoses and/or how disabled I am? I believe it does, and then I'll have to do some WCAB procedure? And should I get an atty for this procedure to protect my rights?

    4. Do I need to get a lawyer now rather than waiting for the QME results because waiting until then may put me dangerously close to this 104 week cut-off for disability benefits, and whatever the QME says is pretty much written in stone?

    5. Can I go through my own insurance to see an ortho or neuro? I believe these WC doctors are missing something because my CTS supposedly shouldn't be causing pain, etc. in my neck and shoulder, yet being TTD for almost a year hasn't resolved the pain, or significantly improved my ROM in those areas.

  • Wed, Dec 12 2007 3:23 PM In reply to

    • TeriLM1
    • Top 500 Contributor
    • Joined on Mon, Jul 23 2007
    • Posts 90

    Feedback [*=*] re: Am I about to be thrown under the bus? Req for QME...

    If it were me, I would get an attorney. Then you could get an AME instead of a QME. I hear they're a bit better; I don't know for sure. The QME/AME get paid by the IC. I believe that they do try to please them. That's where an attorney comes in. They know when things don't seem right (usually). You can do it alone. Read previous posts because there are very helpful tips and links from experienced people who have helped me and other IWs.
    My appt with the AME did take months, but the report and formula took about one month. That varies by doctors/adjusters.
    I don't know about your 5th question, but someone else will. Also, the AME report does trump everyone else's, but you can fight to change it.
  • Wed, Dec 12 2007 3:28 PM In reply to

    • mchmjh
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    • Joined on Wed, Dec 12 2007
    • Posts 19

    Question [=?] re: Am I about to be thrown under the bus? Req for QME...

    Thanks for your reply. Question: What do you mean by "formula"?
  • Wed, Dec 12 2007 3:41 PM In reply to

    • j999
    • Top 200 Contributor
    • Joined on Sun, May 2 2004
    • Posts 155

    re: Am I about to be thrown under the bus? Req for QME...


    Below is from my own personal experiences and opinions, others on here can give you more legal type answers and more experienced info.

    My experiences were all pre-2004 law – I don’t know if anything has chanced on qme/ame drs since the new law.

    When they sent me to a QME, that was THEIR DR, He is not 'neutral'.

    Each side is allowed 1 QME – so you will get a chance to counter any report by the insurance’s qme.

    It is an AME that you only get 1 doctor that is supposed to be ‘neutral’ to both sides

    I haven’t had any experience with an AME – I said no – because the Insurance QME’s report was in my favor and they only wanted an AME so that they could get a counter report against Their Own Qme’s report; each side only gets a choice of 1 qme and they couldn’t therefore send me to another qme themselves just because they didn’t like the report by their own choice.

    I tape recorded both appts with insurance's QME.
    The only thing required for taping was that I notify him prior to the appt date so that he too could tape record our appt.

    A suggestion from my own mistake:
    I did not record the exam itself the 1st time and I did not verbalize what was going on visually.
    Like: I am having a hard time sitting because of the pain it causes, it is difficult to get up and down from a sitting position
    (doctors watch you while they talk with you, not just during exam – and they can get really creative on those type of things since you can’t tape record that unless you comment on it as you do it).
    Think of everything as an exam of your abilities, not just the exam itself.

    If you get an attorney, then he/she will decide about having a Qme choosen by your side to counter the insurance qme’s report if there are any major areas of disagreement.

    My 1st qme report from the insurance co was very good; so there was no need to go to a qme from our side
    The 2nd time when I was sent back so that their qme could ‘fix’ his report since they could not change to another qme, of course his report wasn’t as good as the 1st, though it wasn't really bad either, but my atty did send me to a qme for our side to counter the 2nd report.

    Of course you also only get one QME from your side, whether he does a good job or not, you like the insurance co only get 1 choice of qme. Your atty will be the one to decide whether or not to go with a qme for your side and your atty will be the one to choose the qme, normally just based on who they usually work with.

    I strongly recommend interview a few attys and not making a decision right away - good attys will not even try to get you to sign with them right away, they know you need to think about what they have said they can do for you, based on your specific issues from you case, before making a decision who to hire.
    sometimes your pt or dr may be able to recommend who might be a good atty from what they have heard from other patients (and also who to be careful of hiring)

  • Wed, Dec 12 2007 10:15 PM In reply to

    • mchmjh
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    • Joined on Wed, Dec 12 2007
    • Posts 19

    re: Am I about to be thrown under the bus? Req for QME...

    I called my PTP's office today and actually got my current specifc diagnoses as:

    Right CTS
    Chronic Right Shoulder Tendonitis
    Ulnar Neuritis of the Right Elbow

    Not that I think the fancy names really make one bit of difference. :(
  • Fri, Dec 14 2007 5:19 PM In reply to

    • mchmjh
    • Not Ranked
    • Joined on Wed, Dec 12 2007
    • Posts 19

    Ok [+0+] re: Appt. with atty today...

    Wish me luck :)
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