Danville, CA asked in Workers' Compensation for California

Q: Do I see the qme for treatments now that he’s done the evaluation?

I recently went to see the qme and he says that he wants to try physical therapy to see if it will help with my injury. The adjuster told me that I can only see my ptp for 24 months and it’s pretty close to it. Do I need a new ptp or do I just go see the qme for treatments.

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2 Lawyer Answers

Nancy J. Wallace

Answered
  • Workers' Compensation Lawyer
  • Grand Terrace, CA
  • Licensed in California

A: You don't get ANY treatment unless and until (1) a physician from the Insurer's Medical Provider Network sees you and requests that treatment by way of a Request For Authorization form and (2) the adjuster OKs that Request for Authorization form. A QME is just an evaluator, never a treater. Since 2014, we cannot use the opinion of the QME to get a judge to order any treatment. So just because a QME insists you need treatment, the law permits the insurance company to refuse that treatment until their MPN doctor requests that procedure and the insurer's Utilization Review doc 'certifies' that request. if you pick the wrong treating doc, you won't get any treatment, so get an experienced workers comp attorney up there to pick the MPN treater for you asap.

Ronald Mahurin

Answered
  • Workers' Compensation Lawyer
  • Point Arena, CA
  • Licensed in California

A: Neither. Changing doctors will not reset the number of PT visits you are allowed (24) by statute. Generally Utilization Review will only reduce the number of PT visits not cut them off because PT helps in your recovery. In other words, it is foolish for the adjuster to cut off PT. The proper procedure is for you to get a prescription for PT from your treating physician. The PQME does not take over treatment except in very rare circumstances. In fact, there is usually a disclaimer in the PQME report saying the PQME is not providing treatment. So have the PTP write a prescription for PT and go from there.

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