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Surviving the Panel Qualified Med-Legal Process

Surviving the Panel Qualified Med-Legal Process

One of the more sinister aspects of the pro-employer workers’ compensation reform (SB-899) was how doctors are now chosen to do your med-legal evaluation.  These evaluations are extremely important in a claim and can literally determine your fate in the comp system.

If you are unrepresented by an attorney, you can’t get an agreement with the insurance carrier to have a respected doctor evaluate your medical condition.  Such an arrangement is called an Agreed Medical Evaluation “AME.”  These are doctors that both applicant and defense attorneys have worked with for years.  These folks are knowledgeable in their fields, normally fair, and know how to apply the California Labor Code and case law in their evaluations. 

Not so with Panel Qualified Medical Evaluators (PQMEs).  A frightening number of them simply don’t know what they’re doing.  The insurance companies see how conservative many of these panels are and many times will not even agree to an AME with an attorney.  That is why it has become so crucial to keep a database on these doctors to know who to strike (remove) when you have a panel.

It gets much worse.  Orthopedic (bone) injuries account for about one half the claims in California.  A disproportionate percentage of the evaluations done on the orthopedic panels are controlled by a small number of the most conservative physicians in the state. 

Take for example the “Fresno Doctors.”  To be called a “Fresno Doctor” is not a compliment.  There are some notable exceptions to the “Fresno Doctor Syndrome”, but they have become synonymous with the worst that is in store for injured workers in need of thoughtful, reasonable med-legal evaluations.

For the most part, these “Fresno Doctors” do not care about the people they are evaluating.  It is about punching out as many med-legal evaluations as they can and making money.  These doctors will chop off unreasoned chunks of an injured worker’s disability percentages based on apportionment.  Many of their opinions are not based on “substantial medical evidence” as they are not supported by the “how and why” of their analysis.  These doctors will earn their statutory fee for the evaluation and go on to the next case.  Many do not know how the AMA Guides (the book for evaluation of impairment) works and some will not use the proper instruments to evaluate impairment. They will frequently say “no” to industrial causation in cases that are clearly industrial.  It is a vicious racket, and it is state sanctioned.

Here is a scary fact…if you have an orthopedic panel you will not even know who the “Fresno Doctor” is because the doctors will list their address locally!  Guess what, they really are not local doctors, they just get a day’s worth of people to evaluate in your town and it looks like that is where their office is.

There is a larger issue here with PQMEs.  Some of these evaluators are strikingly good, others are complete morons.  They have no inclination to give more accurate, higher impairment percentages in light of the Almaraz/Guzman opinion.   As noted above, sometimes even attorneys have no choice, and have to pick a panel.  It can be a crap shoot if you don’t properly vet these doctors and have a little luck to boot.

Helpful Hint: Steer clear of the orthopedic panels, as they are infested with conservative doctors.  A better choice of med-legal panels would be in physiatrist, chiropractic or general medicine (even if they are not a perfect fit for the injury).

The good news is after 1/1/13, a QME doctor can not have more than 10 locations in the state to do evaluations out of.  This was one of the cooler aspects of the recently passed SB-863. So the “Fresno Doctors” will not be a state wide phenomenon, their damage will be confined to a fewer areas. This will have a tendency to create opportunities for local doctors to do more evaluations. Having said all of this, there is just too much money at stake and I fear that the Fresno Doctors will find a way to get around the rules. We are just going to see what happens in the next few years

Thomas Ledgerwood
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Proprietor Ledgerwood Law Group