The workers’ compensation claims process can be unpredictable. No matter how much you prepare, it is impossible to remove the risk of denial, especially if there are details surrounding your injury that may cause complications. If the claims administrator finds that your paperwork has inconsistent details affecting your eligibility for benefits, you may need to seek further assessment by a qualified medical evaluator (QME).
QMEs are medical practitioners with the credentials to conduct examinations to clarify or resolve the claims administrator’s issues, resulting in disagreement. A physician might only be eligible to do further evaluations if they meet the following conditions:
- They accomplished the licensing and credential requirements to serve as a QME.
- They achieved a passing result in the evaluation process test.
- If they have not taken the test, they must be undergoing formal education about workers’ compensation evaluation.
A QME is just one of the various roles in addressing claims denial. Sometimes, a qualified physician may agree to resolve the issues causing the disagreement. In this scenario, the doctor becomes an agreed medical evaluator (AME).
Once designated as the evaluator, the case will go through an independent medical review (IMR). The results of this process can help determine what happens next.
Knowing what to do and how to do it
Facing a denial for your workers’ compensation claim can be devastating. You could have a lot riding on your benefits, especially if you have no other financial resources to rely on. There is no sure way to avoid claims denial, but you can seek legal counsel. Doing so cannot give you a guarantee of approval. Still, valuable advice and insight can help you navigate the process, guiding you on what you should do and how to do it.