An Adjuster’s Guide to QME Reports

Ask any workers’ compensation claims adjuster, and they’ll likely tell you that reviewing a Qualified Medical Evaluation (QME) or IME (Independent Medical Evaluation) report is one of many tedious documents that they need to review and summarize in the course of adjudicating claims in workers’ compensation, personal injury, or general liability claims. These reports are long, complex, and filled with medical jargon, yet they’re essential for assessing claims accurately and fairly.

But why is the QME review process so time-consuming and challenging?

Why Reviewing a QME Report Takes So Much Time

QME reports are dense and can often reach 50-80 pages, especially when they include extensive medical histories or diagnostic test results. Each report details a claimant’s medical background, current symptoms, diagnostic results, and recommendations for future care. To make matters worse, there’s little standardization across reports, and each QME can look vastly different depending on the physician, the specific injury, and the context of the claim.

For an adjuster, sifting through these lengthy reports to pull out relevant details like impairment ratings, causation analysis, or work restrictions requires extreme attention to detail, since small details hidden inside of the QME can have huge impacts on settlement outcomes like compensability or even liability. It’s a manual process that demands time and a solid understanding of medical terminology—making it an exhausting task.

Reviewing a QME Takes Adjusters Away from Core Decision-Making

It can take an average of 30 minutes to thoroughly review a single QME report. For cases with complex injuries or lengthy histories, this time can easily double. As a result, many insurance companies face a growing backlog of cases, slowing down claims decisions and frustrating both adjusters and claimants.

When adjusters spend hours wading through detailed medical records, it leaves less time for the work they’re trained to do: making informed claims decisions, analyzing complex cases, and providing quality service to claimants.

Key Insights and Strategies for Claims Adjusters

Reviewing a QME report requires careful attention to critical information that can significantly impact a claim. Key dates, injury description consistency, and work restrictions are just some of the details that play a pivotal role in return-to-work planning and determining liability. Keeping an eye on causation analysis, treatment recommendations, and MMI status is also essential, as they guide decisions on future care and compensability. Red flags, such as inconsistencies with prior reports or gaps in medical history, can signal deeper issues and may even lead to disputes if not properly addressed.

Additionally, recent advances in Artificial Intelligence (AI) have recently made technology a viable partner for completing QME reviews and summaries. Artificial intelligence (AI) platforms can extract key information from long medical evaluations in a fraction of the time, saving adjusters hours each week. These AI models rely on titles, headings, and other “structural features” included in medical records to understand what the records contain. Large language models (LLMs), which are capable of reading and writing natural language, can read and pull out relevant information quickly. Adjusters can then use these summaries to quickly update diaries, send out status reports, and generate return-to-work plans or even bring claims to a close, resulting in faster and more accurate settlement decisions.

To streamline the process, claims professionals can benefit from a standardized review approach, documenting essential fields, tracking timelines, leveraging new technologies, and cross-referencing prior reports to ensure consistency. Strategic insights gained from QMEs, such as settlement value impact and litigation risks, support informed decision-making. By focusing on these components, adjusters can approach QME reviews with greater confidence, ultimately leading to more accurate and efficient claims processing.