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QME
08-11-2008, 03:47 PM
Post: #1
QME
Hello again,
I'm the injured nurse in Ca. DX with Cervicl and Thoracic Spondylosis and disc osteophytes at C4-5, C7-T1,and T1-2 posterior disc bulge with Radiculopathy.I also have pain in my left leg. Questionably Siactica.

I have been on TTD since the beginning of March. My Doctor orderd a MRI of my Lumbar. My lawyer called me today to inform me that the Insurance Company is disputing the Ortho Doctor report or rating. The lawyer told me that they will set up an appointment for me to see one of their QME's. He stated," that it will take about 45 days before I'm to see one of their Doctors."

I have an appointment to see the Ortho Doc. tommorrow. I still have not been called with the athorization for the Lumbar MRI. I'm wondering if it's going to be denied. My Claim Adjuster has always, or so it seemed to be caring.

I need some type of perspective as to what I should do. I thought it strange when I saw the Ortho Doc. He asked,"if I have seen a Doctor about my leg pain?" He did tell me that I should be followed bya Rheumatologist, which I'm presently seeing.

Also last week I spoke with my attorney's assistant about receiving copies of all reports from the Doctors, that I have seen since my injury. The Ortho Doc. did state in one report that he beleived my injury was a result of my occupation. I did receive reports from the beginnning of my injury up until May. When I spoke with the attorney today , I asked for the remainder of the reports up until current. He stated that he just recevied the reports the same time he got the fax from the insurance company disputing the Doctor's recommendation.
He seemed to be somewhat agitated about my reqest for the remainder of my reports.
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08-11-2008, 04:31 PM
Post: #2
RE: QME
California uses utilization review to control treatment. If the MRI request is going to be denied the carrier is required to notify the doctor and there is a procedure to have it appealed.
here's a link to the UR process
http://www.dir.ca.gov/dwc/UR_Main.htm
and some information about the QME process
http://www.dir.ca.gov/dwc/MedicalUnit/QME_page.html
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08-11-2008, 08:57 PM
Post: #3
RE: QME
1171 Wrote:California uses utilization review to control treatment. If the MRI request is going to be denied the carrier is required to notify the doctor and there is a procedure to have it appealed.
here's a link to the UR process
http://www.dir.ca.gov/dwc/UR_Main.htm
and some information about the QME process
http://www.dir.ca.gov/dwc/MedicalUnit/QME_page.html

Thank you 1171
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08-12-2008, 05:26 AM
Post: #4
RE: QME
Of course you are at the stage when the ic did not like the rating and will get thier own doctor ( pay him well ) to say that your rating is lower and that you may not even need medication. You will have to go to this QME and the doctor will see you all but 10 mins. and have all your records. 99% of the time the doctor they choose is one they have dealt with in the past to give them a lower rating to save them money. It will probably come back lower. You must have your doctor dispute it and get another opinion if possible so have an appointment set with your own doctor for after the QME.

If it is a big difference in rating, you will have to have a hearing on the rating dispute. At least that is how it works in NH. I am not sure how Ca. does it. Just telling you what happened to me. As soon as that doctor they send you to says that you do not need meds. they stop your medication payments. I did not have a lawyer and ended up with the rating their doctor gave me, and they no longer pay for my meds. This is what they want. To try to get out of paying for things and lower your rating. Just make sure you get all your documents. I also was very close to my adjuster and that makes absolutly NO difference in how nice you are to them. Plus if you have a lawyer your adjuster should not even be talking to you anymore.

WC is not for the people......it is for the insurance co's. Sad but true. It is all to save a buck and dump the injured worker.

carpal tunnel recurrence/ neuropathy / RSD.
1/29/07 injury date. Permanent. PIR settlement 8/4/08 10%
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08-12-2008, 10:15 AM
Post: #5
RE: QME
Each workers experience is different; there is no one way a claim is handle in every state for every worker. Many who come here have had difficulties and are frustrated and angry.
For each one here there are thousands where the claim has gone well. How yours will turn out is unknown but those who know the laws as well as their rights and benefits have more options. Each state has information available to those who want it.
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08-12-2008, 12:18 PM
Post: #6
RE: QME
There is also people on here Jimmy that work for the ic and have no idea how it is to be the INJURED patient trying to get care or compensated for what has happened to them. Yes, there is different ways that each state handles wc claims, but all seem to follow the same path. The insurance co. is looking for the lowest rating possible to pay you or to cut your benefits as much as possible. Unfortunatly the IME or QME doctor is the one most of the time they find the most credible.

I do not know what they gave you for a rating, but can bet you that they will try to get this doctor they hire to put you at a low one and try not to approve a MRI if at all possible. Many people on here have had difficulty getting a MRI done through the ic, and I am one of them. It took me going to a chiropractor to get one done. Hopefully your case does not end up like mine. Get ALL your records to back your injury up. They will try to widdle around it somehow, trust me.

You should also call and request your documents from the doctor after so many visits. Those are your doctors notes and you should not have any trouble obtaining them.

carpal tunnel recurrence/ neuropathy / RSD.
1/29/07 injury date. Permanent. PIR settlement 8/4/08 10%
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08-12-2008, 01:13 PM
Post: #7
RE: QME
Thank you all for the information. I will keep you guys posted.
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08-12-2008, 03:49 PM
Post: #8
RE: QME
I get all of my records directly from the doctors office. If you try to get this stuff from your attorney you'll end up pulling your hair out.
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08-12-2008, 04:06 PM
Post: #9
RE: QME
understand this Jimmy if we lived in a country that cared about their workers none of us would be here....We are here because we are seeking help... some of us have settled and are standing ready to help the IW all we can...And we are not gonna pull any bull with you or take any from the adjusters who troll here either....most of WC cases go thru with no problems then there are those of us that are gonna cost the IC and they hate us.....We will help all we can......

........I love cats, I just cant eat a whole one by myself......
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08-12-2008, 04:54 PM
Post: #10
RE: QME
Well said Jayne!!!!

carpal tunnel recurrence/ neuropathy / RSD.
1/29/07 injury date. Permanent. PIR settlement 8/4/08 10%
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