For Qualified Medical Evaluators, the process of conducting an examination and preparing a report can seem fairly straightforward. The evaluator reviews the available medical records, interviews and examines the applicant, and prepares a report addressing issues such as causation, impairment, apportionment, and future medical treatment. However, some of these determinations depend on whether the applicant has reached Maximum Medical Improvement (MMI)—the point at which the applicant’s condition has stabilized and is not expected to materially improve with or without further treatment.
Typically, a QME is requested when there is a dispute, which means that diagnostic studies or treatment may have been denied.
After completing a few evaluations, a QME may begin to notice a pattern: surprisingly few applicants are actually ready to be declared MMI upon the first visit. The records have been reviewed, the examination has been performed, but something is still missing. Perhaps the applicant needs additional treatment, further diagnostic testing, more time to recover, or additional medical records before a final determination of permanent impairment can be made. If that sounds familiar, you’re not alone. There are several reasons why so many QME evaluations stop short of an MMI determination, and many of them have little to do with the quality of the evaluation itself.
The Applicant Is Still Treating
One simple reason an applicant may not be ready for MMI is that they are still engaged in a course of medical treatment that is reasonably expected to improve their condition. An applicant who has not yet completed a prescribed course of physical therapy, for example, can potentially see progress in areas such as range of motion or grip strength. These improvements can affect the final impairment rating, which is determined at MMI. If impairment is rated before maximum improvement has been established, the rating may not accurately reflect the permanent impairment expected to remain after treatment.
Importantly, the mere fact that treatment is ongoing does not necessarily mean an applicant is not MMI; the question is whether further treatment or recovery is reasonably expected to produce material improvement.
The Medical Workup Isn’t Complete
Sometimes the issue isn’t treatment but information. Often, a QME is asked to evaluate an applicant before all of the necessary diagnostic workup has been completed. Despite the medical data collected during the evaluation, the medical picture is still developing, and there may not be enough information to determine the applicant’s permanent condition.
In these situations, evaluators may need additional testing, such as an MRI, EMG, or nerve conduction study, or may need a consultation with a specialist or surgeon. The applicant may also need treatment that was previously denied. In some cases, the applicant may in fact be at MMI, but the QME is unable to make that determination with the limited information available at the time. Evaluators should identify what is needed to proceed and request it in the report.
Sometimes the Records Aren’t There
Another major obstacle is one that has nothing to do with the applicant’s medical condition: the QME has not received all of the medical information prior to the evaluation. The process for submitting records to a QME is governed by specific regulations, and the volume and timing of those records can create practical problems. A single claim may involve thousands of pages of medical records, which may arrive late, arrive in multiple batches, or not arrive at all. Records may also be accompanied by an invalid declaration or may be missing important documents such as operative reports, diagnostic studies, or subsequent treatment records.
In these situations, the QME may have to prepare a report based on incomplete documentation, with important aspects of the applicant’s history or treatment not yet independently corroborated.
When dealing with incomplete records, the QME must identify and report on what is missing. Additional materials should then be sent later with a request for a supplemental report or further evaluation. In some cases, a QME may go through several rounds of reports before having the information necessary to make a final MMI determination.
The Claim May Never Make It to MMI
There is another reason QMEs may see relatively few cases all the way through to MMI: not every claim remains active long enough to get there. For a number of reasons, some workers’ compensation claims resolve or are settled by the parties while the applicant is still treating or before the QME has made a final determination regarding permanent impairment.
The evaluator may never know that the recent non-MMI report they submitted is actually the final report necessary for the process. The QME’s role is to provide medically supported opinions that help the parties understand the applicant’s condition and move the claim forward. Sometimes that process ends before an MMI determination is necessary.
What Should a QME Do When an Applicant Isn’t MMI?
An MMI declaration should not be viewed as the “goal” of a QME evaluation, as there is a great deal that can be gained from a properly written non-MMI report. A useful non-MMI report should explain why the applicant isn’t ready and, importantly, what needs to happen before that determination can be made.
- Treatment that remains outstanding
- Additional diagnostic testing that is needed
- Recovery time following surgery
- Specialist evaluation that has not yet occurred
- Missing medical records
- Additional information needed to evaluate permanent impairment
At the same time, the QME should still address the issues that can reasonably be determined at the current stage of the case. Opinions on diagnosis, causation, and credibility are typically provided even when the applicant is not MMI. These opinions may be altered in future reports when additional information is provided, but it is valuable for the parties to understand what is indicated at that particular time.
Most importantly, the QME should clearly identify the obstacles that remain before an MMI determination can be made. A well-written non-MMI report can serve as a roadmap for what needs to happen before MMI can be determined. Rather than simply stating that the applicant is not yet permanent and stationary, the QME gives the parties a practical checklist of what remains to be completed. For example, if an applicant has recently undergone surgery, the report should identify the need for postoperative treatment and an appropriate period of recovery before permanent impairment can be assessed. If diagnostic testing, specialist evaluation, or medical records are still outstanding, those items should be clearly identified as well.
That clarity is valuable to everyone involved. The applicant and their attorney can understand what treatment or evaluation remains necessary, while the defense and claims administrator can better understand what information or medical developments are needed before the case can be fully evaluated. When the remaining steps are clearly identified, the parties are in a better position to obtain the necessary information, complete the appropriate treatment, and determine when a final evaluation is appropriate.
A Fair Perspective on the Process
For a QME, it can be tempting to view an MMI determination as the natural endpoint of every evaluation, but the reality is that it is all part of a process. In fact, it is very rare that an initial evaluation will result in a permanent and stationary report. Sometimes the applicant has not yet undergone necessary evaluation or treatment. Sometimes the records are not complete enough for the QME to confirm the applicant’s status based on substantial medical evidence.
The goal of a QME evaluation isn’t simply to reach MMI. It’s to accurately reflect the medical reality of the applicant’s condition and clearly identify what is needed to reach the next step in the process. By doing so, the QME can help guide the parties toward resolution by giving them a clear understanding of what remains to be done and a clear path forward.