Can a QME Be Disqualified in California Workers’ Compensation?
Yes. A Qualified Medical Evaluator can be disqualified—either for a single case or from the statewide roster—when statutory rules are breached. Disqualification ranges from being removed from one panel to full suspension or revocation of your QME certification. Understanding the triggers and due-process steps will help you steer clear of costly pitfalls.
Grounds for Case-Specific Disqualification
- Conflict of Interest – Prior treatment of the claimant, financial ties to a party, or ownership in a clinic that billed the claim.
- Ex Parte Communication – Substantive contact with one side without the other’s knowledge, in violation of CCR §35.
- Untimely Scheduling or Reporting – Failure to offer an appointment within 60 days or to serve the report within 30 days.
- Specialty Mismatch – Selected for a specialty you are not board-certified or qualified to perform.
If any of these arise, a party may petition the DWC Medical Unit (Form 31.5) for a replacement QME. You lose the case and any unpaid fees.
Administrative Suspension or Revocation
For more serious—or repeated—violations, the Medical Unit may open a formal investigation under CCR §60:
- Accusation Filed – Lists alleged violations (e.g., chronic late reports, fraudulent billing, license probation).
- Administrative Hearing – You may present evidence and be represented by counsel before an ALJ.
- Decision & Order – Outcomes range from probation with CME requirements to full revocation of your QME number.
Preventive Best Practices
- Run conflict checks on every new panel assignment.
- Channel all substantive communications through joint, written correspondence.
- Use deadline trackers for the 60-/30-day rules.
- Self-audit reports quarterly for AMA-rating and billing accuracy.
For recent suspension lists and procedural details, visit the DWC’s QME Suspension & Revocation page.