For Qualified Medical Evaluators (QMEs) working within California’s Workers’ Compensation system, there is a strict expectation that the opinions presented in QME reports be based not only on the applicant’s stated history and the results of the physical examination, but also on a complete and thorough review of properly submitted medical records. While the contents of those records can be critical for understanding the applicant’s medical history, treatment, and progress, a QME must first determine whether the records have been submitted in compliance with the applicable regulations. Properly submitted records can help unlock the details of a claim, while improperly submitted records must remain sealed, serving only to delay the evaluation process. For this reason, it is important for QMEs to be familiar with California’s medical-legal regulations governing record submissions and the professional obligations they face when those requirements are not met.
One of the most common procedural issues encountered during medical-legal evaluations involves the submission of records without a compliant declaration. As outlined in regulation 8 CCR §9793(n), any records, medical or otherwise, provided to a QME or AME must be accompanied by a valid declaration. To be considered valid, the declaration must, under penalty of perjury, state that the provider has complied with the provisions of Labor Code §4062.3 before furnishing the documents to the evaluator, and it must include an attestation regarding the page count of the submitted records.
These requirements exist for good reason, as they seek to preserve the integrity of the medical-legal evaluation process. The declaration serves as the evaluator’s assurance that the records have been exchanged in accordance with the Labor Code. By taking steps to ensure that records are exchanged in accordance with the procedural safeguards established by California law, the process provides a sense of fairness and impartiality, which is the foundation that Workers’ Compensation is built upon.
The rules regarding the declaration are also clear about an evaluator’s responsibilities when these requirements are not properly met. In these situations, the records are not considered available to the evaluator for purposes of the evaluator’s regulatory or statutory duties regarding records and report writing. An evaluator also may not bill for review of documents that are not provided with this accompanying required declaration.
Despite the lack of reviewable records, a report is still required following the evaluation. By documenting the situation properly within the QME report, an evaluator can provide insight into why opinions could not be reached or are being deferred until records are properly sent. This inclusion helps clarify the situation for attorneys and adjusters, and it allows for the records to be resubmitted. To this end, many evaluators choose to document in their report that the materials were received but were not reviewed because they did not comply with the requirements of 8 CCR §9793(n).
The bottom line for QMEs is straightforward but important. Before reviewing records, confirm that they have been properly submitted. If the required declaration is missing or somehow invalid, DO NOT REVIEW THE RECORDS. Instead, document the issue within the report, explain how the deficiency affects the evaluation, and request any and all records be sent to you for inclusion in a supplemental report. Taking these steps helps to protect the integrity of the evaluation, the QME process, and your position as an evaluator.