Current through Reg. 49, No. 38; September 20, 2024
(a) Qualifications
to get or renew certification. The division will not assign examinations to a
designated doctor who does not meet all requirements for certification or
renewal. All designated doctors must:
(1) Have
a complete designated doctor certification application as described in
subsection (b) of this section on file with the division.
(2) Complete all division-required trainings
within 12 months of the date of application and have current documentation
confirming their completion on file with the division.
(3) Pass all division-required testing on the
specific duties of a designated doctor under the Labor Code and division rules
and have current documentation confirming their passage on file with the
division. Required testing must have been completed on or after May 13, 2013,
and includes demonstrated proficient knowledge of the currently adopted edition
of:
(A) the American Medical Association
Guides to the Evaluation of Permanent Impairment; and
(B) the division's adopted:
(i) treatment guidelines; and
(ii) return-to-work guidelines.
(4) Have maintained an
active practice for at least three years during the doctor's career. For the
purposes of this subsection, a doctor has an active practice if the doctor
maintains or has maintained routine office hours of at least 20 hours per week
for 40 weeks per year to treat patients.
(5) For the duration of the doctor's term as
a designated doctor:
(A) be licensed in
Texas;
(B) own or subscribe to the
current edition of the American Medical Association Guides to the Evaluation of
Permanent Impairment adopted by the division to assign impairment ratings and
all return-to-work and treatment guidelines adopted by the division;
and
(C) comply with financial
disclosure requirements in §
180.24(relating to Financial
Disclosure) of this title.
(b) Application. To be considered complete,
an application for certification must include, and a renewal application must
update or confirm:
(1) contact information for
the doctor;
(2) information on the
doctor's education;
(3) a
description of the doctor's license or licenses, certifications, and
professional specialty, if any;
(4)
a description of the doctor's work history and hospital or other health care
provider affiliations;
(5) a
description of any affiliations the doctor has with a workers' compensation
health care network certified under Insurance Code Chapter 1305 or political
subdivision under Labor Code §
504.053(b)(2);
(6) information on the doctor's current
practice locations;
(7) detailed
answers to disclosure questions on the doctor's professional background,
education, training, and fitness to perform the duties of a designated doctor,
including disclosure and summary of any disciplinary actions taken against the
doctor by any state licensing board or other appropriate state or federal
agency;
(8) the identity of any
person the doctor has contracted with to assist in performing or administering
the doctor's designated doctor duties;
(9) an attestation that:
(A) all information provided in the
application is accurate and complete to the best of the doctor's
knowledge;
(B) the doctor will
inform the division of any changes to this information as required by §
127.200(a)(8) of
this title (relating to Duties of a Designated Doctor); and
(C) the doctor will consent to any on-site
visits, as provided by §
127.200(a)(15) of
this title, by the division at facilities that the designated doctor uses or
intends to use to perform designated doctor examinations for the duration of
the doctor's certification.
(c) Retesting. If a doctor passes a
division-required test, the doctor may not retest within a twelve-month period.
If a doctor fails a division-required test, the doctor may not retest more than
three times within a six-month period.
(1)
After the first or second attempt, the doctor must wait 14 days before retaking
the test.
(2) After the third
attempt, the doctor must wait six months before retaking the test.
(d) Additional certification
testing. On receipt of an application for designated doctor certification
renewal, the division may require a designated doctor to complete additional
certification testing to demonstrate proficient knowledge on the specific
duties of a designated doctor under the Labor Code and division rules. Examples
of circumstances that may require additional certification testing include, but
are not limited to, individual need for retesting based on substandard
performance, changes in the duties of a designated doctor, updates to the
guidelines, and legislative changes.
(e) Notice of approval, denial, suspension,
or revocation. The division will notify a doctor in writing of the
commissioner's approval or denial of the doctor's application to be certified
or renewed as a designated doctor; or of the division's suspension or
revocation of the doctor's certification.
(f) Term and qualification. Approvals certify
a doctor for a term of two years and will include:
(1) the effective date of the
certification;
(2) the expiration
date of the certification; and
(3)
the designated doctor's examination qualifications under §
127.130 of this title (relating to
Qualification Standards for Designated Doctor Examinations).
(g) Renewal. A designated doctor
who seeks to renew their certification immediately after their current term
expires, without interruption, must apply for certification no later than 45
days before the end of the term.
(1) If the
division does not receive all of the information required under subsection
(b)(1) - (9) above no later than 45 days before the end of the designated
doctor's term, the division will not assign examinations to the designated
doctor during the last 45 days of an expiring term.
(2) The designated doctor may still provide
services on claims the division had previously assigned to them during this
45-day period.
(h)
Approval of renewal application with restrictions. An application for renewal
may be approved with restrictions. The division may restrict a designated
doctor's certification until the doctor complies with the requirements in the
designated doctor's approval of certification. Designated doctors whose
certification is restricted may dispute the restriction through the procedure
described in subsection (k) of this section.
(i) Adverse certification actions. The
division may deny, suspend, or revoke a designated doctor's certification for
any of the following reasons:
(1) if the
doctor did not submit a complete application for certification as required
under subsection (b) of this section;
(2) for having a relevant restriction on
their practice imposed by a state licensing board, certification authority, or
other appropriate state or federal agency, including the division;
(3) if the doctor failed to update their
application for certification properly; or
(4) for other activities, events, or
occurrences that the commissioner determines warrant denial of a doctor's
application for certification as a designated doctor, including, but not
limited to:
(A) the quality of the designated
doctor's past reports;
(B) the
designated doctor's history of complaints;
(C) excess requests for deferral from the
designated doctor list by the designated doctor;
(D) a pattern of overturned reports by the
division or a court;
(E) a
demonstrated lack of ability to apply or properly consider the American Medical
Association Guides to the Evaluation of Permanent Impairment adopted by the
division to assign impairment ratings and all return-to-work and treatment
guidelines adopted by the division;
(F) a demonstrated lack of ability to
consistently perform designated doctor examinations in a timely
manner;
(G) a demonstrated failure
to identify disqualifying associations;
(H) a demonstrated lack of ability to ensure
the confidentiality of injured employee medical records and claim information
provided to or generated by a designated doctor;
(I) a history of unnecessary referral
examinations or testing;
(J) a
failure to comply with the requirements of §
180.24 of this title (relating to
Financial Disclosure) when they requested referral examinations or additional
testing;
(K) applying for
certification less than a year from denial of a previous designated doctor
certification application; or
(L)
any grounds that would allow the division to sanction a health care provider
under the Labor Code or division rules.
(j) Response to denial of certification.
Within 15 working days after receiving a written denial, a doctor may file a
written response with the division addressing the reasons the division gave to
the doctor for its denial.
(1) If the division
does not receive a written response by the 15th working day after the date the
doctor received the notice, the denial will be final effective the next day.
The division will not send further notice.
(2) If the division timely receives a written
response that disagrees with the denial, the division will review the response
and notify the doctor in writing of the commissioner's final decision.
(A) If the final decision is still a denial,
the division's final notice will provide the reasons the doctor's response did
not change the commissioner's decision to deny the doctor's application for
certification as a designated doctor.
(B) The denial will be effective the day
after the doctor receives notice of the denial, unless the notice specifies
otherwise.
(k)
Request for informal conference. A designated doctor whose renewal application
is denied, or whose certification is suspended or revoked, may either respond
in writing using the procedure in subsection (j) of this section or submit a
written request for an informal conference before the division to address those
reasons.
(1) If the division does not receive
a written request for an informal conference by the 15th working day after the
date the doctor received the notice, the denial, suspension, or revocation will
be final effective the next day. The division will not send further
notice.
(2) If the division timely
receives a written request for an informal conference, it will set the informal
conference to occur no later than 31 days after it received the request.
(A) At the informal conference, the
designated doctor may present evidence that addresses the reasons the doctor
was denied certification, or the reasons the doctor's certification was
suspended or revoked, to the commissioner's designated
representatives.
(B) The designated
doctor may have an attorney present.
(C) At the end of the informal conference,
the commissioner's designated representatives will provide the designated
doctor with their final recommendation on the doctor's certification.
(i) If the final recommendation is still a
denial, suspension, or revocation, the commissioner's designated
representatives will provide the reasons for not certifying the doctor as a
designated doctor.
(ii) After the
informal conference, the commissioner's designated representatives will send
their final recommendation to the commissioner, who will review it and all
evidence presented at the informal conference and make a final
decision.
(iii) The division will
notify the designated doctor of the commissioner's final decision in
writing.
(iv) The decision will be
effective the day after the doctor receives notice of the decision, unless the
notice specifies otherwise.
