When someone gets injured at work or requires some kind of specialized medical treatment, insurance companies get wary. Before they are willing to pay some insurance claims, particularly Worker’s Compensation claims, they want an independent assessment that confirms certain treatments are necessary. It’s a Qualified Medical Evaluator (QME) who will be called in to do QME evaluation.

What is a Qualified Medical Evaluator?

A QME is a licensed physician who holds a license to practice medicine within their state of residence. In order to qualify to serve as a QME, they need to take designated classes and pass subsequent testing in order to receive QME certification. Once they obtain their QME certification, they must take continuing education classes in order to maintain their status.


What is the Role of a QME?

When a medical treatment claim is sent to an insurance company for preauthorization, the insurance company has to decide whether or not to approve the associated treatment or procedure. If they have any doubts about the validity or scope of a claim, they will hire a QME to provide a QME evaluation of the medical situation.

The primary role of a QME is to meet with the patient to determine the extent of the patient’s medical condition. The guideline for such an evaluation varies from one state to the next. In some states, the QME is required to meet “Face to Face” with each patient for a certain amount of time.

During the QME evaluation process, the QME will review the patient’s medical and hospital records. They do this to rule out the possibility of a preexisting condition that might account for the injury.

The next step in the process is to interview the patient and give them a comprehensive physical exam to confirm the extent of the injury and assess the patient’s pain levels. The range of evaluations a QME could provide includes:

  • Neuromusculoskeletal Evaluations
  • Cardiovascular Evaluations
  • Pulmonary Evaluations
  • Psychiatric Evaluations
  • General Evaluations

The QME has no responsibility regarding the rejection or approval of a medical claim. Their job is simply to attest to the validity of the claim.

After receiving a QME evaluation, the insurance company will make a final determination regarding the claim. It is possible that a QMW might suggest a different form of treatment, a suggestion that would put a lesser financial burden on the insurance company.