Disclosure Requirements for QME Reports in California — and Why IMEs Should Take Note

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We want to share an important update following the recent WCAB panel decision in Manuel Gurrola Martinez v. H & H Wallboard, Inc. (ADJ16350553). The case is a reminder that strict compliance with California Labor Code §4628 (the state’s anti-ghostwriting statute) is essential for QMEs, and it also reflects a broader industry shift toward transparency, physician authorship, and disclosure in med-legal reporting that IMEs should be mindful of as well.

MediScan AI is a physician-first workspace designed to keep you efficient and compliant while using AI to augment your workflow. You remain the sole author of your reports, with full oversight, editable chronologies, and built-in disclosure language that makes compliance straightforward.

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What LC §4628 Requires

• Personal performance: The QME must perform all non-clerical tasks.
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• Disclosure: Anyone who assists must be identified by name and qualifications.
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• Independent judgment: Physicians must review records themselves and make their own conclusions.
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• Strict liability: Even unintentional non-compliance can render a report inadmissible and unpaid, with potential penalties for violations.

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What the Gurrola Martinez Decision Means

In this case, the physician did not disclose the use of a third-party record summarization service. The WCAB granted reconsideration on procedural grounds but reinforced that undisclosed assistance is not permitted under LC §4628.

The message is clear: reports must reflect the physician’s own work, and all assistance must be transparent.

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Practical Concerns from Physicians

Physicians have asked what this means for reports they’ve already submitted, especially if they didn’t include explicit disclosure language. The key issue is authorship. If the physician reviewed records themselves, made independent judgments, and finalized the report in their own words, then the report reflects their authorship and responsibility under LC §4628. Disclosure is a safeguard for clarity and cross-examination, but its absence in past reports does not automatically mean non-compliance. What matters most is that the physician (not software or outside services) remains in control of the analysis and final report.

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Additional Guidance: DWC and AMA

Beyond the case itself, two important authorities provide further direction on AI use in med-legal reporting:

• The California Division of Workers’ Compensation (DWC) advises:

“If artificial intelligence is used in the medical legal report process, please consult with your licensing board as to disclosure... It appears consistent to disclose the use of artificial intelligence by listing at a minimum the name of the program and the purpose for which it is used.” (DIR News Release 2024-60)

• The American Medical Association (AMA) has stated that AI in health care must be

‍“designed, developed, and deployed in a manner that is ethical, equitable, responsible, and transparent.” (AMA AI Principles)

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Taken together, the WCAB decision, DWC checklist, and AMA principles all emphasize the same theme: physician oversight and full disclosure are the standard.

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How MediScan AI Supports Compliance

MediScan AI was designed as a physician-first workspace, not a ghostwriting service. With MediScan:

• You remain the sole author of your reports.
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• All activity is logged to demonstrate physician oversight.
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• Findings and chronologies are fully editable so you can verify and finalize every detail.
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• We provide suggested disclosure language so your reports remain transparent.

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Suggested Disclosure

To make compliance simple, you can include language like this in your reports:

“In preparing this evaluation, I personally reviewed all medical records and performed the analysis necessary for my conclusions. I utilized MediScan AI, a HIPAA-compliant physician-workspace software, to organize and surface key information for my review. I independently verified all information, and the opinions expressed herein are my own.”

This makes it clear that MediScan is a tool, not a ghostwriter.

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Regarding the placement of your disclosure, there's no exact placement, but here's what we are suggesting: Near the Declaration of Accuracy / Perjury Statement‍

• Place the disclosure immediately before or after the physician’s required declaration that the report is true and correct under penalty of perjury.
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• This keeps it in the formal attestation section of the report, where it is least likely to be overlooked.

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Alternatively, in the Methodology or Introduction Section

‍If you include a standard “Records Reviewed” or “Methodology” section, you can insert the disclosure there, stating that MediScan AI was used as a tool to organize records and surface key information, with the physician personally verifying all conclusions.

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Cross-Examination Tip

If you are cross-examined, the most straightforward and compliant answer is:

• Yes, you wrote the report yourself.
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• You used MediScan as a tool to organize and review records, but the interpretation, edits, and final report are entirely your work.
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• The disclosure language is an added safeguard for transparency, but your past reports still reflect your authorship and compliance.

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The Bottom Line

The Gurrola Martinez decision signals closer scrutiny for QMEs in California, but the broader message also matters for IMEs. Physicians across med-legal work are expected to show clear authorship, transparency, and oversight in their reporting.

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With the right practices—personal authorship, clear disclosures, AMA-aligned AI use, and reliable tools that support physician control—compliance and trust remain straightforward.

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While WCAB panel decisions are not binding precedent, they are citable and reflect how the Board is likely to view undisclosed assistance under LC §4628.

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MediScan AI was built to help physicians, whether serving as QMEs or IMEs, work more efficiently while maintaining transparency and compliance.

Book a quick demo to see how it works.

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