Functioning within the Division of Workers’ Compensation (DWC) Medical Unit (MU), the Qualified Medical Evaluator (QME) Investigations and Enforcement Section reviews complaints regarding QME physicians to determine qualifying and disqualifying factors relevant to QME certification. The decisions to approve or deny QME certifications are made according to the regulations adopted by the Administrative Director (AD).
In concurrence with the DWC Legal Unit, the Investigations and Enforcement Section also evaluates applications for QME appointment or reappointment to determine the adequacy of information provided, licensing board discipline, criminal convictions, or prior QME violations.
How to File a Complaint
- Complete the QME Complaint form to report suspected QME physician violations. Submit the complaint form by email at QMEInvestigations@dir.ca.gov or by mail to:
DWC Medical Unit
QME Investigations and Enforcement Section
P.O. Box 71010
Oakland, CA 94612
Additional information regarding complaints may be obtained by contacting the DWC Medical Unit at (800) 794-6900. Select prompt one (1) for the QME program, and then select prompt seven (7) to inquire about a complaint against a QME physician.
The Complaint Process
- The public assists the QME Investigations and Enforcement Section by submitting the QME Complaint form to report when QME physicians are suspected of violating the California Code of Regulations, Title 8, Section 60.
- The section gathers, prepares, and maintains evidentiary documentation to assist the DWC Legal Unit in prosecuting disciplinary matters before the Office of Administrative Hearings.
- Investigations outcomes include the suspension or termination of QME physician certifications, or placing QME physicians on probation.
- AD actions which result in disciplinary outcomes are noted in the Medical Unit Disciplined Physician’s list.
Note: The complete investigation and litigation of a complaint can be lengthy, and has no bearing on the outcome of an individual’s workers’ compensation case.
Common Reasons to File a Complaint
Common reasons to file a complaint include, but are not limited to:
- Injured worker not treated professionally - 8 CCR § 41 (a)(5)
QMEs must communicate with injured workers in a courteous, professional and respectful manner during their evaluation.
- Billing Issues – LC § 4620 (a) and (c), 4628(i) and 53076; 8 CCR § 9793 and 9795
QMEs may only bill the medical insurance company according to the medical-legal fee schedule. An injured worker may report a QME who charges a fee to schedule an evaluation.
- Discrimination 8 CCR § 41 (c)(3) and (d); Gov. C 11135; LC 1171.5
A QME’s expert opinions or conclusions shall not be reflective of the injured worker’s race, sex, national origin, religion or sexual preference.
- Waiting Time – 8 CCR 41§ (f)
A QME is in violation of this regulation if the injured worker waits beyond one hour in the doctor’s office prior to the evaluation.
See the California Code of Regulations, Title 8 for more information.
- California Code of Regulations, Title 8, Sections 60-65
- QME Complaint form
- Disciplined Physician’s list
- FAQs about QMEs for injured workers
- FAQs about QMEs for physicians
- File a complaint against medical providers suspected of workers’ compensation fraud
- File a complaint against insurance companies, self-insured employers, and third-party administrators