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§ 127.210. Designated Doctor Administrative Violations

(a) In addition to the grounds for issuing sanctions against a doctor under § 180.26 of this title (relating to Criteria for Imposing, Recommending, and Determining Sanctions; Other Remedies), other division rules, or the Texas Workers’ Compensation Act, the commissioner may revoke or suspend a designated doctor’s certification as a designated doctor or otherwise sanction a designated doctor for noncompliance with requirements of this chapter or for any of the following:

(1) four refusals within a 90-day period to accept or perform a division offered appointment or ordered appointment for which the doctor is qualified and that relates to a claim to which the doctor has not been previously assigned;

(2) four consecutive refusals to perform within the required time frames a division ordered appointment for which the doctor is qualified and that relates to a claim to which the doctor has not been previously assigned;

(3) any refusal to accept or perform a division offered appointment or ordered appointment that relates to a claim on which the doctor has previously performed an examination;

(4) misrepresentation or omission of pertinent facts in medical evaluation and narrative reports;

(5) submitting unnecessary referrals to other health care providers for the answering of any question submitted to the designated doctor by the division;

(6) ordering or performing unnecessary testing of an injured employee as part of a designated doctor’s examination;

(7) submission of inaccurate or inappropriate reports due to insufficient medical history or physical examination and analysis of medical records;

(8) submission of designated doctor reports that fail to include all elements required by § 127.220 of this title (relating to Designated Doctor Reports), § 127.10 of this title (relating to General Procedures for Designated Doctor Examinations), and other division rules;

(9) failure to timely respond to a request for clarification from the division regarding an examination or any other information request by the division;

(10) failure to successfully complete training and testing requirements as specified in § 127.110 of this title (relating to Designated Doctor Recertification);

(11) self-referring, including referral to another health care provider with whom the designated doctor has a disqualifying association, for treatment or becoming the employee’s treating doctor for the medical condition evaluated by the designated doctor;

(12) behaving in an abusive or assaultive manner toward an injured employee, the division, or other system participant;

(13) failing to maintain the confidentiality of patient medical and claim file information;

(14) performing a designated doctor examination which the designated doctor was not ordered by the division to perform; or

(15) other violations of applicable statutes or rules while serving as a designated doctor.

(b) Designated doctors are liable for all administrative violations committed by their agents on the designated doctor’s behalf under this section, other division rules, or any other applicable law.

(c) The process for notification and opportunity for appeal of a sanction is governed by § 180.27 of this title (relating to Restoration) except that suspension, revocation, or other sanction relating to a designated doctor’s certification will be in effect during the pendency of any appeal.

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

The provisions of this §127.210 adopted to be effective September 1, 2012, 37 TexReg 5422.

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At a Glance:

Title:

§ 127.210. Designated Doctor Administrative Violations

Title:

Title 28. Insurance

Status:

Current

Usage:

New Law Rule

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