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§ 127.200. Duties of a Designated Doctor

(a) All designated doctors shall:

(1) perform designated doctor examinations in a facility currently used and properly equipped for medical examinations or other similar health care services and that ensures safety, privacy, and accessibility for injured employees and injured employee medical records and other records containing confidential claim information;

(2) ensure the confidentiality of medical records, analyses, and forms provided to or generated by the designated doctor in the doctor’s capacity as a designated doctor for the duration of the retention period specified in § 127.10(i) of this title (relating to General Procedures for Designated Doctor Examinations) and ensure the destruction of these medical records after both this retention period expires and the designated doctor determines the information is no longer needed;

(3) ensure that all agreements with person(s) that permit those parties to perform designated doctor administrative duties, including but not limited to billing and scheduling duties, on the designated doctor’s behalf:

(A) are in writing and signed by the designated doctor and the person(s) with whom the designated doctor is contracting;

(B) define the administrative duties that the person may perform on behalf of the designated doctor;

(C) require the person or persons to comply with all confidentiality provisions of the Act and other applicable laws;

(D) comply with all medical billing and payment requirements under Chapter 133 of this title (relating to General Medical Benefits);

(E) do not constitute an improper inducement relating to the delivery of benefits to and injured employee under Labor Code § 415.0036 and § 180.25 of this title (relating to Improper Inducements, Influence and Threats); and

(F) made available to the division upon request;

(4) notify the division in writing and in advance if the designated doctor voluntarily decides to defer the designated doctor’s availability to receive any offers of examinations for personal or other reasons and the notice must specify the duration of and reason for the deferral;

(5) notify the division in writing and in advance if the designated doctor no longer wishes to practice as a designated doctor before the doctor’s current certification as a designated doctor expires; a designated doctor who no longer wishes to practice as a designated doctor before the doctor’s current certification expires must expressly surrender the designated doctor’s certification in a signed, written statement to the division;

(6) be physically present in the same room as the injured employee for the designated doctor examination or any other health care service provided to the injured employee that is not referred to another health care provider under § 127.10(c) of this title;

(7) apply the appropriate edition of the American Medical Association Guides to the Evaluation of Permanent Impairment and division-adopted return-to-work guidelines and consider division-adopted treatment guidelines or other evidence-based medicine when appropriate;

(8) provide the division with updated information within 10 working days of a change in any of the information provided to the division on the doctor’s application for certification or recertification as a designated doctor;

(9) maintain a professional and courteous demeanor when performing the duties of a designated doctor, including, but not limited to, explaining the purpose of a designated doctor examination to an injured employee at the beginning of the examination and using non-inflammatory, appropriate language in all reports and documents produced by the designated doctor;

(10) bill for designated doctor examinations and receive payment for those examinations in accordance with Chapter 133 of this title and Chapter 134 of this title (relating to Benefits–Guidelines for Medical Services, Charges, and Payments);

(11) respond timely to all division appointment, clarification, or document requests, or other division inquiries;

(12) notify the division if a designated doctor’s continued participation on a claim to which the designated doctor has already been assigned would required the doctor to exceed the scope of practice authorized by the doctor’s license;

(13) not perform required medical examinations, utilization reviews, or peer reviews on a claim to which the designated doctor has been assigned as a designated doctor;

(14) identify themselves at the beginning of every designated doctor examination;

(15) consent to and cooperate during any on-site visits by the division pursuant to § 180.4 of this title (relating to On-Site Visits); notwithstanding § 180.4(e)(2) of this title, the division’s purpose for these visits will be to ensure the designated doctor’s compliance with the Act and applicable division rules, and the notice provided to the designated doctor in accordance with § 180.4 of this title, either in advance of or at the time of the on-site visit, will specify the duties being investigated by the division during that visit;

(16) cooperate with all division compliance audits, quality reviews; and

(17) otherwise comply with all applicable laws and rules.

(b) For the purposes of this chapter, Chapter 180 of this title (relating to Monitoring and Enforcement), and all other applicable laws and division rules, any person with whom a designated doctor contracts or otherwise permits to perform designated doctor administrative duties on behalf of the designated doctor qualifies as the doctor’s “agent” as defined under § 180.1 of this title (relating to Definitions).

(c) This section will become effective on September 1, 2012.

The provisions of this §127.200 adopted to be effective September 1, 2012, 37 TexReg 5422.

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At a Glance:

Title:

§ 127.200. Duties of a Designated Doctor

Title:

Title 28. Insurance

Status:

Current

Usage:

New Law Rule

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