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Special Report: Revisions to Medical-Legal Evaluation Regulations

The Division of Workers' Compensation (DWC) revised regulations related to medical-legal evaluations effective Feb. 2, 2023. The regulations make changes to the rules for scheduling QME examinations and permanently adopt regulations allowing remote medical-legal evaluations. Specifically, the regulations make these changes to the medical-legal process:

  1. The time limits for a QME appointment have been extended by 30 days. So a QME appointment must be scheduled within 90 days of an appointment request, although the scheduling party may accept an appointment no more than 120 days after the initial request for it.

  2. The time limit for a QME appointment applies to both the initial comprehensive medical-legal evaluation and any request for follow-up evaluations.

  3. The regulations maintain the rule that the first QME examination must be at the office selected on the panel selection form, but the parties, by written agreement, may allow the initial examination to occur at any office listed with the medical director.

  4. A QME or AME who cancels a scheduled appointment must reschedule it within 60 calendar days of the date of cancellation, unless the parties agree in writing to accept an appointment beyond that limit. Previously, a QME was required to reschedule the appointment within 30 days of the date of cancellation.

  5. Rules allowing remote medical-legal evaluations when specified criteria are met are adopted permanently.

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In the Initial Statement of Reasons for the regulations, the DWC explained that additional time to schedule an appointment with a QME is necessary to increase the availability of such appointments. It explained that in 2019, the DWC replaced 24,995 panels because a physician was not available in 60 days; in 2021, when the time for scheduling was 90 days, the DWC replaced only 10,267 panels for that reason.

The DWC explained that it revised the regulations to allow an initial evaluation at any office listed with the medical director by written agreement by the parties to address scheduling delays. Similarly, it explained that allowing 60 days to reschedule a canceled appointment would afford physicians more scheduling flexibility, which would lead to more appointments being scheduled by the initially selected QME.

Finally, the DWC permanently adopted the emergency regulations allowing remote medical-legal evaluations. Per CCR 46.3, a QME or AME may complete a medical-legal evaluation through remote health when a hands-on physical examination is not necessary and all of these conditions are met:

  1. A medical issue is in dispute that involves whether the injury is AOE/COE, or the physician is asked to address the termination of an injured worker’s indemnity benefit payments, or address a dispute regarding work restrictions.

  2. The injured worker, the carrier or employer and the evaluator agree in writing to the remote health evaluation.

  3. The remote health evaluation conducted via virtual meeting is consistent with appropriate and ethical medical practices and the AMA guides, 5th edition, as determined by the QME and the relevant medical licensing board.

  4. The evaluator attests in writing that the evaluation does not require a physical exam.

Notably, CCR 46.3 eliminates language in the former emergency regulation stating that an agreement to a remote evaluation could not be unreasonably denied. In the comments to the regulations, the DWC explained that the language was deleted because it was deemed repetitive. The DWC noted that the parties continue to have the right to seek the assistance of the appeals board, which has jurisdiction to adjudicate compensation claims and disputes related to the QME process.

The revised regulations, and their history, are available on the DWC website. The changes made by the regulations primarily are found in Sullivan on Comp Section 14.40 Appointment and Cancellation and Section 14.44 Evaluation Requirement and Rights.

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