www.twcc.state.tx.us
and then clicking on "Laws,
Rules & Forms" and then clicking on "Proposed Rules." This medium for
commenting will help you organize your comments by rule chapter. You may also
comment by emailing your comments to
RuleComments@
twcc.state.tx.us
or by mailing or delivering your comments to Linda
Velasquez, Legal Services, Mailstop #4-D, Texas Workers' Compensation Commission,
7551 Metro Center Drive, Suite 100, Austin, Texas 78744-7551.
Commenters are requested to clearly identify by number the specific rule
and paragraph commented upon. The commission may not be able to respond to
comments that cannot be linked to a particular proposed rule. Along with your
comment, it is suggested that you include the reasoning for the comment in
order for commission staff to fully evaluate your recommendations.
Based upon various considerations, including comments received and the
staffs' or commissioners' review of those comments, or based upon the commissioners'
action at the public meeting, the rule as adopted may be revised from the
rule as proposed in whole or in part. Persons in support of the rule as proposed,
in whole or in part, may wish to comment to that effect. Persons who disagree
with the timeframes proposed in these amendments are encouraged to suggest
alternate timeframes with reasons for the suggested changes.
A public hearing on this proposal will be held on June 16, 2004, at the
Austin central office of the commission (Texas Workers' Compensation Commission,
7551 Metro Center Drive, Suite 100, Austin, Texas). Those persons interested
in attending the public hearing should contact the Commission's Office of
Executive Communication at (512) 804-4030 to confirm the date, time, and location
of the public hearing for this proposal. The public hearing schedule will
also be available on the commission's website at
www.twcc.state.tx.us
.
The rule amendments are proposed pursuant to: the Texas Labor Code §401.011
which contains definitions used in the Texas Workers' Compensation Act; the
Texas Labor Code §401.024, which provides the Commission the authority
to require use of facsimile or other electronic means to transmit information
in the system; the Texas Labor Code §402.042, which authorizes the Executive
Director to enter orders as authorized by the Act as well as to prescribe
the form and manner and procedure for transmission of information to the Commission;
the Texas Labor Code §402.061, which authorizes the Commission to adopt
rules necessary to administer the Act; the Texas Labor Code §406.010,
which authorizes the Commission to adopt rules regarding claims service; the
Texas Labor Code §408.021, which states an employee who sustains a compensable
injury is entitled to all health care reasonably required by the nature of
the injury as and when needed; the Texas Labor Code §408.022, which address
choice of treating doctor; the Texas Labor Code §408.023, which requires
the Commission to develop a list of approved doctors and lay out the requirements
for being on the list and which grants the Commission the authority to provide
for exceptions to the requirement to be on the ADL, as necessary to ensure
that employees have access to health care; the Texas Labor Code §408.0231,
which provides the Commission with the responsibility for maintenance of the
list, with the authority for imposing sanctions, and requires the Commission
to adopt rules; the Texas Labor Code §408.025 which requires the Commission
to specify by rule what reports a health care provider is required to file;
the Texas Labor Code §413.002, which requires the Commission to monitor
health care providers and carriers to ensure compliance with Commission rules
relating to health care including medical policies and fee guidelines; the
Texas Labor Code §413.011, which requires the Commission by rule to establish
medical policies relating to necessary treatments for injuries and designed
to ensure the quality of medical care and to achieve effective medical cost
control; the Texas Labor Code §413.012, which requires the Commission
to review and revise medical policies and fee guidelines at least every two
years to reflect current medical treatment and fees that are reasonable and
necessary; the Texas Labor Code §413.013, which requires the Commission
by rule to establish a program for prospective, concurrent, and retrospective
review and resolution of a dispute regarding health care treatments and services;
a program for the systematic monitoring of the necessity of the treatments
administered and fees charged and paid for medical treatments or services
including the authorization of prospective, concurrent or retrospective review
and a program to detect practices and patterns by insurance carriers in unreasonably
denying authorization of payment for medical services, and a program to increase
the intensity of review; the Texas Labor Code §413.014, which requires
the Commission to specify by rule, except for treatments and services required
to treat a medical emergency, which health care treatments and services require
express preauthorization and concurrent review by the carrier as well as allowing
health care providers to request precertification and allowing the carriers
to enter agreements to pay for treatments and services that do not require
preauthorization or concurrent review. This mandate also states the carrier
is not liable for the cost of the specified treatments and services unless
preauthorization is sought by the claimant or health care provider and either
obtained or ordered by the Commission; the Texas Labor Code §413.017,
which establishes medical services to be presumed reasonable when provided
subject to prospective, concurrent review and are authorized by the carrier;
the Texas Labor Code §413.031, which establishes the right to access
medical dispute resolution; the Texas Labor Code §413.041, which requires
financial disclosure of financial interests by health care providers and their
employers, which requires the Commission to adopt federal standards prohibiting
payment of acceptance of payment in exchange for health care referrals, and
which prohibits payment to a provider during a period of noncompliance with
disclosure requirements; the Texas Labor Code §413.0511, which creates
the position of Medical Advisor and imbues the position with certain responsibilities
and authority; the Texas Labor Code §413.0512, which creates the Medical
Quality Review Panel (MQRP) and grants it certain responsibilities and authority;
certain responsibilities and authority; the Texas Labor Code §413.0513,
which lays out confidentiality provisions relating to the MQRP; the Texas
Labor Code §414.007, which allows the review of referrals from the Medical
Review Division by the Division of Compliance and Practices; and; the Texas
Labor Code §415.0035, which establishes administrative violations for
repeated administrative violations.
The rule amendments are proposed pursuant to: the Texas Labor
Code §§401.011, 401.024, 402.042, 402.061, 406.010, 408.021, 408.022,
408.023, 408.0231, 408.025, 413.002, 413.011, 413.012, 413.013, 413.014, 413.017,
413.031, 413.041, 413.0511, 413.0512, 413.0513, 414.007, 415.0035.
The previously cited sections of the Texas Labor Code are affected by this
proposed rule. No other code or statute is affected by this proposal.
§180.20.Commission Approved Doctor List.
(a)
This section governs the commission's approved doctor list
(ADL). Except in an emergency, as defined in §133.1 of this title (relating
to Definitions For Chapter 133) or for the immediate post-injury medical care,
as defined in §180.1 of this title (relating to Definitions) injured
employees (employees) shall receive health care from a doctor on the ADL:
(1)
The ADL established by the statute and commission rules
as it exists on August 31, 2003 is null and void as of September 1, 2003.
Any doctor on the ADL prior to September 1, 2003 who does not reapply to be
on the ADL or whose application is not approved will not be on the ADL as
of September 1, 2003.
(2)
On or after September 1, 2003, doctors who provide any
functions in the Texas workers' compensation system are required to be on
the ADL.
(b)
Until September 1, 2003, unless deleted from the list by
the commission, the ADL includes all doctors licensed in Texas on or after
January 1, 1993, and doctors licensed in other jurisdictions who have been
added to the list by the commission. Doctors licensed in other jurisdictions
may ask to be added to the list by submitting a written request containing
information prescribed by the commission. Doctors on the ADL on or after September
1, 2003, whether licensed in Texas or licensed by another jurisdiction, shall
have:
(1)
successfully completed the training required by §180.23(h)
of this title (relating to Commission Required Training for Doctors/Certificate
of Registration Levels);
(2)
applied for a Certificate of Registration with the commission
in the form and manner prescribed by the commission; and
(3)
disclosed financial interests as required by Texas Labor
Code §413.041 and §180.24 of this title (relating to Financial Disclosure)
with the application.
(c)
An incomplete application for registration to be admitted
to the ADL pursuant to this section shall be rejected and shall not be processed.
A complete application shall include:
(1)
general contact information including, but not limited
to: name, mailing address, voice and facsimile numbers, and an email address;
(2)
the training module taken and date completed;
(3)
Impairment Rating Skills Examination score, if applicable;
(4)
verification of licensure;
(5)
disciplinary actions or practice restrictions by an appropriate
licensing or certification authority, if any;
(6)
an agreement that the doctor will comply with the Statute
and Rules, including but not limited to, cooperating with commission monitoring
and review efforts such as audits by the commission and paying audit bills
when required by Statute or Rule;
(7)
if the doctor applying for the ADL is not licensed in this
state but wishes to perform utilization review and/or peer reviews for an
insurance carrier or its agent, the applicant must certify that the reviews
will be performed under the direction of a doctor who is licensed in this
state and has an ADL Level 2 Certificate of Registration (as provided in §180.23
of this title). The carrier requesting such a review must ensure that the
work was performed under the direction of an appropriate in-state doctor,
and, upon request, must identify the in-state doctor and present documentation
that the review was performed under the direction of that doctor; and
(8)
if the doctor is applying for a Level 1 Certificate of
Registration with a Non-Medical Management designation as provided in §180.23(c)(1)(D)
of this title, the doctor must indicate in the appropriate place on the application
that the doctor's practice does not include ongoing medical management, including
pain management, of injured employees.
(d)
The commission may utilize members of the Medical Quality
Review Panel for evaluating ADL applications and making recommendations to
the Medical Advisor to approve, approve with condition(s) or restriction(s),
or deny admission to the ADL.
(e)
The commission may grant a temporary exception to the requirement
to be on the ADL to ensure that employees have access to health care pending
commission action on a doctor's application. A doctor with a temporary exception
must meet all the requirements that doctors on the ADL must meet. A temporary
exception does not constitute "being on the ADL," "approval to be on the ADL,"
or "denial of an application to be on the ADL."
(f)
Doctors shall be denied admission to the ADL or admitted
with condition(s) or restriction(s) for:
(1)
failing to complete required training;
(2)
having relevant restriction(s) on their practice (including,
but not limited to, prior deletion from the ADL); or
(3)
other activities which warrant application denial or restriction
such as grounds that would require or allow the Medical Advisor to recommend
deletion of a doctor from the ADL or other sanction of a doctor as specified
in §180.26 of this title (relating to Doctor and Insurance Carrier Sanctions)
or the Statute and Rules.
(g)
The commission shall notify a doctor of the commission's
approval
, approval with condition(s) or restriction(s),
or denial
of the doctor's application to the ADL.
(1)
Denials or approvals with condition(s) or restriction(s)
shall include the reason(s) for the action.
(2)
Within
15
[
14
] days after receiving
the notice, the doctor may file a response [
,
] which addresses
the
reason(s)
[
reasons
] given for the denial or admission
with
condition(s) or
restriction(s).
(A)
If a response is not received by the 15th day after the
date the doctor received the notice, the action shall be final
effective
the following day. No
[
and no
] further notice shall be sent.
(B)
If a response which disagrees with the action is timely
received, the commission shall review the response and shall notify the doctor
of the commission's final decision. If the final decision is not an unrestricted
approval, the commission's final notice shall
provide
[
explain
] the
reason(s)
[
reason
] why the doctor's response
did not convince the commission to grant the doctor an unrestricted admission
to the ADL.
The denial or admission with condition(s) or restriction(s)
shall be effective the day following the date the doctor receives notice of
the final decision unless otherwise specified in the notice.
(3)
Notwithstanding other provisions
of this subsection, for denials pursuant to §180.20(f)(1) of this title,
and for denials pursuant to §180.20(f)(3) of this title wherein the subsection
of §180.26 relied upon is §180.26(b), and within five working days
(as defined by §102.3(b) of this title) after receiving the notice, the
doctor may file a response which addresses the reason(s) given for the denial.
(A)
If a response is not received by the fifth working
day after the date the doctor received the notice, the action shall be final
effective the following day. No further notice shall be sent.
(B)
If a response which disagrees with the action
is timely received, the commission shall review the response and shall notify
the doctor of the commission's final decision. A final decision denying the
doctor admission to the ADL shall provide the reason(s) why the doctor's response
did not convince the commission to grant the doctor admission to the ADL.
The denial shall be effective the day following the date the doctor receives
notice of the denial unless otherwise specified in the notice.
(4)
[
(3)
] All notices under this subsection
shall be delivered by a verifiable means.
Date of receipt for notices
shall be determined in accordance with §102.5(d) of this title.
(5)
[
(4)
] The fact that the commission
did not take action to deny admission to a doctor or admit a doctor with condition(s)
or restriction(s) to the ADL does not waive the commission's right to review
or further review a doctor and take action at a later date.
(h)
Chapter 133 of this title (relating to Benefits - Medical
Benefits) applies to all medical bills, including those from doctors who were
not on the ADL at the time the health care was rendered.
(1)
All licensed doctors, whether on the ADL or not, are entitled
to reimbursement in accordance with the Statute and Rules for providing reasonable
and necessary emergency or immediate post-injury medical care.
(2)
A doctor is entitled to reimbursement in accordance with
the doctor's level of Certificate of Registration and the Statute and Rules
for directly or indirectly providing reasonable and necessary health care
(other than emergency or immediate post-injury medical care) or other medical
services (such as peer reviews or other evaluations) if:
(A)
the doctor was on the ADL at the time the service was provided;
(B)
the doctor was granted a temporary exception to the requirement
to be on the ADL at the time the service was provided; or
(C)
the doctor has been granted an exception on a case-by-case
basis as provided in §180.23(b) of this title, and the claim for which
the doctor is billing is one for which the doctor has been granted an exception.
(3)
A doctor who is entitled to reimbursement based on paragraph
(2)(A) and (B) of this subsection may perform medical services and bill for
those services only after notification of such entitlement from the commission.
(4)
A carrier who receives a bill from a doctor who is not
entitled to reimbursement pursuant to paragraph (2) of this subsection shall
deny the medical bill and send the required explanation of benefits (EOB)
with the appropriate payment exception code.
(5)
Notwithstanding this subsection, a doctor's entitlement
to direct or indirect reimbursement for health care or medical opinions directly
or indirectly provided (other than for emergency or immediate post-injury
medical care) may be limited by sanction imposed by the commission.
(i)
The commission shall make available through its Internet
website the names, licensure and other identification information, and ADL
or ADL exception status of:
(1)
doctors who are not on the ADL because their applications
were denied;
(2)
doctors on the ADL (including a description of any privileges,
conditions or restrictions placed on the doctor by the commission);
(3)
doctors deleted or suspended from the ADL or otherwise
sanctioned by the commission (including a description of the sanction);
(4)
doctors reinstated to the ADL or whose sanctions were lifted
by the commission; and
(5)
doctors granted a temporary exception from the requirement
to be on the ADL pursuant to subsection (e) of this section or on a case-by-case
basis.
(j)
Doctors who are on the ADL or who have applied to be on
the ADL shall provide the commission with updated information within 30 days
of a change in any of the information provided to the commission on the doctor's
ADL application.
(k)
Level 1 Certificates of Registration are valid for two
years from date of issuance, and Level 2 Certificates of Registration are
valid for four years from date of issuance unless the Certificate provides
otherwise, the date is revised by agreed settlement pursuant to §180.26
of this title (relating to Doctor and Insurance Carrier Sanctions) or Texas
Government Code §2001.056 (relating to Informal Disposition of Contested
Case), Commission order or decision, or the doctor has been removed from the
ADL. Upon expiration of a doctor's Certificate of Registration, the doctor
must reapply for the ADL.
§180.21.Commission Designated Doctor List.
(a)
In order to serve as a designated doctor, a doctor must
be on the Designated Doctor List (DDL).
(b)
To be on the DDL prior to September 1, 2003, the doctor
shall at a minimum:
(1)
be currently active on the Approved Doctor List (ADL) as
set forth in Texas Labor Code §408.023 and §180.20 of this title
(relating to Commission Approved Doctor List);
(2)
have maintained for the past three years and continue to
maintain an active practice;
(3)
have filed a request to be on the DDL in the form and manner
prescribed by the commission and been approved by the commission; and
(4)
meet the following training requirements:
(A)
have successfully completed commission-approved training
in the proper use of the AMA Guides prior to submission of an application;
(B)
have successfully completed commission-approved training
at least every two years from the date of the last training; and
(C)
have passed the commission-approved written examination
for impairment rating training within the timeframe specified by the commission.
(c)
To be on the DDL on or after September 1, 2003, the doctor
shall at a minimum:
(1)
be currently active on the ADL with a Level 2 Certificate
of Registration with no condition(s) or restriction(s), or have a temporary
exception to the requirement to be on the ADL, as set forth in Texas Labor
Code §408.023 and §180.20 of this title;
(2)
have had an active practice for one year during their career;
(3)
be fully authorized to assign impairment ratings and certify
maximum medical improvement (MMI) under §180.23(i) of this title (relating
to Commission Required Training for Doctors/Certificate of Registration Levels);
(4)
have filed a request in the form and manner prescribed
by the commission, and have been approved by the commission to be included
on the DDL; and
(5)
either maintain an active practice or successfully complete
commission-approved supplemental training on medical issues relevant to workers'
compensation and/or serving as a designated doctor. Supplemental training
shall be completed between 18 and 30 months following the doctor's passing
the test required to obtain and retain full MMI/impairment authorization.
(d)
An incomplete application for registration to be admitted
to the DDL pursuant to this section and other Rules shall be rejected and
shall not be processed. A complete application shall include:
(1)
general contact information including, but not limited
to: name, mailing address, voice and facsimile numbers and an email address;
(2)
the training certificate indicating the level of training
completed;
(3)
Impairment Rating Skills Examination score;
(4)
verification of licensure;
(5)
information on the doctor's training and experience in
various types of health care and injury areas; and
(6)
disciplinary actions or practice restrictions by an appropriate
licensing or certification authority, if any.
(e)
The commission may utilize members of the Medical Quality
Review Panel (MQRP) for evaluating DDL applications and making recommendations
to the Medical Advisor to approve or deny admission to the DDL. The commission
may also utilize members of the MQRP regarding deletion, suspension, or other
sanction of a designated doctor as provided in this section.
(f)
Doctors shall be denied admission to the DDL:
(1)
if the doctor does not meet the requirements of subsection
(c)(1) of this section;
(2)
if the doctor has not completed required training in accordance
with §180.23(i) of this title and passed the commission approved test;
(3)
for failing to submit a complete application in accordance
with this section;
(4)
for having a relevant restriction on their practice (including,
but not limited to, prior deletion from the ADL or DDL or a prior ADL restriction);
or
(5)
for other activities which warrant application denial such
as grounds that would require the Medical Advisor to recommend deletion of
a doctor from the ADL or other sanction of a doctor as specified in §180.26
of this Title (relating to Doctor and Insurance Carrier Sanctions) or the
Statute and Rules.
(g)
The commission shall notify a doctor of the commission's
approval or denial of the doctor's application to the DDL.
(1)
Denials shall include the reason(s) for the denial.
(2)
Within
15
[
14
] days after receiving
the notice, the doctor may file a response which addresses the reasons given
for the denial.
(A)
If a response is not received by the 15th day after the
date the doctor received the notice, the denial shall be final
effective
the following day. No
[
and no
] further notice shall be sent.
(B)
If a response which disagrees with the denial is timely
received, the commission shall review the response and shall notify the doctor
of the commission's final decision. If the final decision is a denial, the
commission's final notice shall
provide
[
explain
] the
reason why the doctor's response did not convince the commission to admit
the doctor to the DDL.
The denial shall be effective the day following
the date the doctor receives notice of the denial unless otherwise specified
in the notice.
(3)
Notwithstanding other provisions
of this subsection, for denials pursuant to §§180.21(f)(1)-(3) of
this title, and for denials pursuant to §180.21(f)(5) wherein the subsection
of §180.26 relied upon is §180.26(b), and within five working days
(as defined by §102.3(b) of this title) after receiving the notice, the
doctor may file a response which addresses the reason(s) given for the denial.
(A)
If a response is not received by the fifth working
day after the date the doctor received the notice, the action shall be final
effective the following day. No further notice shall be sent.
(B)
If a response which disagrees with the action
is timely received, the commission shall review the response and shall notify
the doctor of the commission's final decision. A final decision denying the
doctor admission to the DDL shall provide the reason(s) why the doctor's response
did not convince the commission to grant the doctor admission to the DDL.
The denial shall be effective the day following the date the doctor receives
notice of the denial unless otherwise specified in the notice.
(4)
[
(3)
] All notices under this subsection
shall be delivered by a verifiable means.
Date of receipt for notices
shall be determined in accordance with §102.5(d) of this title.
(5)
[
(4)
] The fact that the commission
did not take action to deny or restrict admission to the DDL does not waive
the commission's right to review or further review a doctor and take action
at a later date.
(h)
When necessary because the injured employee is temporarily
located or is residing out-of-state, the commission may waive any of the requirements
as specified in this rule for an out-of-state doctor to serve as a designated
doctor to facilitate a timely resolution of the dispute.
(i)
Doctors on the DDL shall provide the commission with updated
information within 30 days of a change in any of the information provided
to the commission on the doctor's DDL application.
(j)
In addition to the grounds for deletion or suspension from
the ADL or for issuing other sanctions against a doctor under §180.26
(of this title), the commission shall delete or suspend a doctor from the
DDL, or otherwise sanction a designated doctor for noncompliance with requirements
of this section or any of the following:
(1)
four refusals within a 90-day period, or four consecutive
refusals to perform within the required time frames, a commission requested
appointment for which the doctor is qualified;
(2)
misrepresentation or omission of pertinent facts in medical
evaluation and narrative reports;
(3)
having a pattern of practice of unnecessary referrals to
other health care providers for the assignment of an impairment rating or
determination of MMI;
(4)
submission of inaccurate or inappropriate reports as a
pattern of practice due to insufficient examination and analysis of medical
records;
(5)
willful failure to timely respond to a request for clarification
from the commission regarding an examination or failure to timely respond
as a pattern of practice;
(6)
assignments of MMI and/or impairment ratings overturned
in a contested case hearing, appeals panel decision and/or court decision;
(7)
any of the factors listed in subsection (f) of this section
that would allow for denial of admission to the DDL;
(8)
failure to timely successfully complete training and testing
requirements as specified in subsections (b) or (c) of this section;
(9)
failure to notify the commission field office of any disqualifying
association within 48 hours of receiving notice of being selected as a designated
doctor as a pattern of practice or conducting an examination when there is
a disqualifying association;
(10)
failure to maintain an active practice or failure to maintain
the alternate training requirements outlined in subsection (c)(5) of this
section;
(11)
self-referring for treatment or becoming the employee's
treating doctor for the medical condition evaluated by the designated doctor;
or
(12)
other significant violation of Statute and/or Rules while
serving as a designated doctor.
(k)
The process for notification and opportunity for appeal
of a sanction is governed by §180.27 of this title (relating to Sanctions
Process/Appeals) except that suspension, deletion, or other sanction relating
to the DDL shall be in effect during the pendency of any appeal.
(l)
The commission shall make available through its Internet
website the names of:
(1)
doctors on the DDL;
(2)
doctors deleted or suspended from the list or otherwise
sanctioned by the commission (including a description of the sanction); and
(3)
doctors reinstated to the list or whose sanctions were
lifted by the commission.
(m)
When a doctor is added to the DDL or readmitted following
a suspension or deletion, the doctor shall be placed at the bottom of the
list for rotation purposes under Texas Labor Code §408.0041.
(n)
The following definitions apply to this section:
(1)
Active practice--a doctor has an active practice if the
doctor maintains routine office hours of at least 20 hours per week for the
treatment of patients.
(2)
Disqualifying Association--any association which may reasonably
be perceived as having potential to influence the conduct or decision of the
designated doctor.
(A)
A disqualifying association between a designated doctor
and a party may include:
(i)
receipt of income, compensation, or payment of any kind
not related to health care provided by the doctor;
(ii)
shared investment or ownership interest;
(iii)
contracts or agreements that provide incentives, such
as referral fees, payments based on volume or value, and waiver of beneficiary
coinsurance and deductible amounts;
(iv)
contracts or agreements for space or equipment rentals,
personnel services, management contracts, referral services, or warranties,
or any other services related to the management of the doctor's practice;
(v)
personal or family relationships; or
(vi)
any other financial arrangement that would require disclosure
under §180.24 of this title (relating to Financial Disclosure).
(B)
Receipt of normal payments rendered for services provided
pursuant to managed care/preferred provider contracts, or any payment in accordance
with the Texas Workers' Compensation Act and rules, is not a disqualifying
association.
(3)
Party--any of the following entities including any of their
agents or representatives: the insurance carrier, health care provider (including
designated doctor and treating doctor), injured employee, or employer.
(4)
Self-Refer--treatment by the designated doctor or referral
for treatment to another health care provider with which the designated doctor
has a disqualifying association.
§180.27.Sanctions Process/Appeals/Restoration/Reinstatement.
(a)
If the commission intends to take action under §180.26
(relating to Doctor and Insurance Carrier Sanctions) or action against a designated
doctor under §180.21 (relating to Commission Designated Doctor List),
other than in the case where a progressive disciplinary agreement under §180.26(e)
was entered into, the commission shall notify the person ("person" also includes
a carrier) to be sanctioned by verifiable means of the commission's intent.
(1)
Not later than 20 days after receiving the notice, a doctor
may request a hearing at the State Office of Administrative Hearings by filing
such a request with the Chief Clerk of Proceedings at the commission.
(2)
If no request for hearing is filed within the time allowed,
the recommendation for sanction will be reviewed by the commissioners at a
public meeting and a decision made. If a hearing was held, the commissioners
shall review the decision of the administrative law judge (ALJ) after the
hearing is held.
(b)
If the commission modifies, amends, or changes a recommended
finding of fact or conclusion of law, or order of the ALJ, the commission's
final order shall state the legal basis and the specific reasons for the change.
(c)
If the commissioners vote to impose the sanction, the commission
shall notify the person by issuing an order of which describes the effects
of the sanction. This order shall be delivered by verifiable means with a
copy to the appropriate licensing or certification authority and, if the sanction
is against a doctor, copies shall be delivered to those injured employees
the commission is aware are being treated by that doctor.
(d)
Failure to comply with the sanction may result in further
sanctioning by the commission.
(e)
A person who was sanctioned can apply to have the sanction
lifted (whether through restoration of privileges or recertification) by applying
in the form and manner prescribed by the commission.
(1)
The request shall be evaluated by the Medical Advisor and
/or members of the Medical Quality Review Panel. The requestor shall be liable
for the cost of the review, which may include an audit of the records of the
requestor.
(A)
If, in the Medical Advisor's opinion, the person has all
the appropriate unrestricted licenses/certifications, has overcome the conditions
that resulted in sanction, and should be reinstated, the Medical Advisor shall
recommend that the commissioners reinstate the doctor or restore the privileges
removed or restricted by the sanction.
(B)
If, in the Medical Advisor's opinion, the person has not
met the requirements for reinstatement or restoration of privileges, the commission
shall notify the person by verifiable means of the intent to recommend to
the commissioners that the sanctions not be lifted. Within
15
[
14
] days after receiving the notice, a doctor may file a response that
addresses the reasons given that the recommendation was to be made. The Medical
Advisor shall review the response and make a final recommendation to the commissioners.
A copy of the requestor's response to the commission shall be provided to
the commissioners for consideration.
(2)
The commissioners shall consider the matter in a public
meeting and shall notify the requestor by verifiable means with a copy to
the appropriate licensing or certification authority. If the commissioners
choose to not lift the sanction, the commissioners may include in their final
decision the conditions that the sanctioned person must meet before the commission
will reconsider lifting the sanctions including, but not limited to, the amount
of time that the person must wait prior to rerequesting lifting the sanction.
(f)
Notwithstanding any other provision of this section, deletion
from the Approved Doctor List by the Executive Director pursuant to §180.26(b)
of this title
shall be governed by this subsection.
(1)
Prior to deletion, the Executive Director or designee shall
notify a doctor of the intention to delete the doctor and the grounds for
that action.
(2)
Within
five working
[
14
] days
(as defined by §102.3(b) of this title)
after receiving the notice
of intent, a doctor may file a response to the reasons given as grounds for
the deletion with the Executive Director or designee.
(A)
If a response is not received by the
fifth working
[
15th
] day after the date the doctor received the notice
of intent, the doctor
shall be
[
is
] deleted
effective
the following day. No
[
and no
] subsequent notice
shall
[
will
] be sent.
(B)
If the response is agreement, the doctor
shall
[
will
] be deleted effective on the earlier of the date the doctor agrees
to the deletion or the
day following the fifth working
[
15th
] day after the date the doctor received the notice of intent
.
No
[
and no
] subsequent notice
shall
[
will
] be sent.
(C)
If a response which disagrees with the grounds for deletion
is timely received and after reviewing the response, the Executive Director
or designee determines:
(i)
that the grounds do not exist for deletion under §180.26(b)
of this title
, the doctor shall be notified that he was not deleted
[
under §180.26(b)
]; or
(ii)
that the grounds for deletion do exist
under §180.26(b)
of this title
, the doctor shall be
deleted effective the day following
the date the doctor receives notice of the deletion unless otherwise specified
in the notice.
[
notified of the deletion and the notice shall identify
the effective date of the deletion.
]
(3)
All notices under this subsection shall be delivered by
a verifiable means.
Date of receipt for notices shall be determined in
accordance with §102.5(d) of this title.
This agency hereby certifies that the proposal has been
reviewed by legal counsel and found to be within the agency's legal authority
to adopt.
Filed with the Office of
the Secretary of State on April 19, 2004.
TRD-200402579
Susan Cory
General Counsel
Texas Workers' Compensation Commission
Earliest possible date of adoption: May 30, 2004
For further information, please call: (512) 804-4287