Current through Reg. 49, No. 38; September 20, 2024
(a) Health care providers as defined in
subsections (c) - (e) of this section shall provide all health care reasonably
required by the nature of the injury as and when needed to:
(1) cure or relieve the effects naturally
resulting from the compensable injury;
(2) promote recovery; or
(3) enhance the ability of the injured
employee to return to or retain employment.
(b) In addition to the general requirements
of this section, health care providers shall timely and appropriately comply
with all applicable requirements under the Act and department and division
rules, including, but not limited to:
(1)
reporting required information;
(2)
disclosing financial interests;
(3)
impartially evaluating an injured employee's condition;
(4) correctly billing for health care
provided;
(5) examine an injured
employee to determine a date of maximum medical improvement and design
impairment ratings as and when appropriate; and
(6) complying with all applicable provisions
of the Americans with Disabilities Act.
(c) The treating doctor is the doctor
primarily responsible for the efficient management of health care and for
coordinating the health care for an injured employee's compensable injury. The
treating doctor shall:
(1) except in the case
of an emergency, approve or recommend all health care reasonably required that
is to be rendered to the injured employee including, but not limited to,
treatment or evaluation provided through referrals to consulting and referral
doctors or other health care providers, as defined in this section;
(2) maintain efficient utilization of health
care;
(3) communicate with the
injured employee, injured employee's representative, if any, employer, and
insurance carrier about the injured employee's ability to work or any work
restrictions on the injured employee;
(4) make available, upon request, in the form
and manner prescribed by the division:
(A)
work release data;
(B) cost and
utilization data; and/or
(C)
patient satisfaction data, including comorbidity, patient outcomes,
return-to-work outcomes, functional health outcomes, and recovery expectations;
and
(5) examine an
injured employee to determine a date of maximum medical improvement and assign
impairment ratings when appropriate.
(d) The consulting doctor is a doctor who
examines an injured employee or the injured employee's medical record in
response to a request from the treating doctor, the designated doctor, or the
division. The consulting doctor shall:
(1)
perform unbiased evaluations of the injured employee as directed by the
requestor including, but not limited to, evaluations of:
(A) the accuracy of the diagnosis and
appropriateness of the treatment of the injured employee;
(B) the injured employee's work status,
ability to work, and work restrictions;
(C) the injured employee's medical condition;
and
(D) other similar
issues;
(2) submit a
narrative report to the treating doctor, the injured employee, the injured
employee's representative (if any), the insurance carrier, and the division (if
the requestor was the division);
(3) not make referrals without the approval
of the treating doctor and when such approval is obtained, ensure that the
health care provider to whom the consulting doctor is making an approved
referral knows the identity and contact information of the treating
doctor;
(4) initiate or provide
treatment only if the treating doctor approves or recommends the treatment;
and
(5) become a referral doctor if
the doctor begins to prescribe or provide health care to an injured
employee.
(e) The
referral doctor is a doctor who examines and treats an injured employee in
response to a request from the treating doctor. The referral doctor shall:
(1) supplement the treating doctor's
care;
(2) timely report the injured
employee's status to the treating doctor and the insurance carrier as required
by applicable division rules; and
(3) not make referrals without the approval
of the treating doctor and when such approval is obtained, ensure that the
health care provider to whom the referral doctor is making an approved referral
knows the identity and contact information of the treating doctor.
(f) The Required Medical
Examination (RME) doctor is a doctor who examines the injured employee's
medical condition in response to a request from the insurance carrier or the
division pursuant to Labor Code §§
408.004,
408.0041,
or
408.151.
The RME doctor shall:
(1) perform unbiased
evaluations of the injured employee as directed by the RME notice issued by the
division;
(2) not make referrals
without the approval of the treating doctor and when such approval is obtained,
ensure that the health care provider to whom the RME doctor is making an
approved referral knows the identity and contact information of the treating
doctor;
(3) initiate or provide
treatment only if the treating doctor approves or recommends the treatment;
and
(4) not evaluate, except
following an examination by a designated doctor:
(A) the impairment caused by the injured
employee's compensable injury;
(B)
the attainment of maximum medical improvement;
(C) the extent of the injured employee's
compensable injury;
(D) whether the
injured employee's disability is a direct result of the work related
injury;
(E) the ability of the
injured employee to return to work; or
(F) issues similar to those described by
subparagraphs (A) - (E) of this paragraph; and
(5) be a doctor licensed to practice medicine
in Texas that holds the appropriate credentials as defined in §
180.1 of
this title (relating to Definitions);
(A) a
dentist that performs dental services under the Act may review dental services
that may lawfully be performed within the scope of the dentist's license to
practice dentistry; or
(B) a
chiropractor that performs chiropractic services under the Act may review
chiropractic services that may lawfully be performed within the scope of the
chiropractor's license to engage in the practice of chiropractic.
(g) A peer reviewer is
a health care provider who performs an administrative review at the insurance
carrier's request without a physical examination of the injured employee. The
peer reviewer must not have any known conflicts of interest with the injured
employee or the health care provider who has proposed or rendered any health
care being reviewed.
(1) A peer reviewer who
performs a prospective, concurrent, or retrospective review of the medical
necessity or reasonableness of health care services (utilization review) is
subject to the applicable provisions of the Labor Code; Insurance Code,
Chapters 1305 and 4201; and department and division rules. A peer reviewer who
performs utilization review must:
(A) be
certified or registered as a utilization review agent (URA) by the department
or be employed by or under contract with a certified or registered URA to
perform utilization review;
(B)
hold the appropriate professional license issued by this state; and
(C) hold the appropriate credentials as
defined in §
180.1 of
this title.
(2) A peer
reviewer who performs a review for any issue other than medical necessity, such
as compensability or an injured employee's ability to return to work, must:
(A) hold the appropriate professional license
issued by this state; and
(B) hold
the appropriate credentials as defined in §
180.1 of
this title.
(h) The designated doctor is a doctor
assigned by the division to recommend a resolution of a dispute as to the
medical condition of an injured employee. At the request of an insurance
carrier or an injured employee, or on the commissioner's own order, the
commissioner may order a medical examination by a designated doctor in
accordance with Labor Code §
408.0041
and §
408.1225. The
credentials, qualifications, and responsibilities of a designated doctor are
governed by § 180.21 of this title (relating to Division Designated Doctor
List), §
180.1 of
this title that defines "appropriate credentials", applicable provisions of the
Act, and other rules providing for use of a designated doctor.
(i) A member of the MQRP is a health care
provider chosen by the division's Medical Advisor under Labor Code §
413.0512.
All eligibilities, terms, responsibilities, and prohibitions shall be
prescribed by contract, and the MQRP members shall serve on the MQRP as
prescribed by contract. A health care provider must meet the performance
standards specified in the contract to be eligible for selection by the Medical
Advisor to serve on the MQRP. A member of the medical quality review panel,
other than a chiropractor or dentist, who reviews a specific workers'
compensation case is subject to Labor Code §
408.0043.
Doctors seeking membership on the MQRP must hold appropriate credentials as
defined in §
180.1 of
this title. A chiropractor who serves on the MQRP and that reviews a
chiropractic service under the Act must be licensed to engage in the practice
of chiropractic pursuant to Labor Code §
408.0045.
A health care provider that serves on the MQRP may only review health care
services or treatment that may lawfully be performed within the scope of the
health care provider's license.
(j)
Independent review organizations (IROs) must comply with the applicable
provisions of Insurance Code, Chapter 4201; Labor Code, Title 5; and Chapters
12, 133 and 180 of this title (relating to Independent Review Organizations;
General Medical Provisions; and Monitoring and Enforcement, respectively). The
division or the department may initiate appropriate proceedings under
applicable provisions of the Insurance Code, Chapter 4201; Labor Code, Title 5;
and Chapters 12, 133 and 180 of this title.
