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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 7. EMPLOYMENT BENEFITS |
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Chapter 7-1. [DELETED] |
Section 7-123. MEDICAL SERVICES AND SUPPLIES: TREATING PHYSICIANS
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123.1 Pursuant to section 2303(a) of the Act, the District government shall furnish to a claimant who is injured while in the performance of duty the services, appliances, and supplies prescribed or recommended by a qualified treating physician, which the Program considers likely to cure, give relief, reduce the degree or injury length, or aid in lessening the amount of the monthly compensation.
123.2In order for the Program to pay for the services provided by a treating physician, the physician must be a member of a panel of treating physicians. The panel shall be selected by the Program.
123.3Physicians shall apply to be members of the panel. The Program shall select members of the panel based on the physicians’ likelihood of meeting the goals of § 123.1. The Program may add and remove physicians from the panel at its discretion.
123.4The Program shall inform a claimant whose claim has been accepted of the requirement in § 123.2 and shall provide the claimant with a list of panel physicians who provide the type of treatment needed by the employee.
123.5If the Program decides to remove a physician from the panel of treating physicians, the Program shall give all of the claimants currently being treated that physician notice of the decision, as well as a list of alternative treating physicians on the panel, thirty (30) days before the physician is removed from the panel.
123.6If a claimant decides to receive treatment from a non-panel physician after the Program provides the claimant with a list of panel physicians, the claimant is not entitled to reimbursement for the cost of services provided by the non-panel physician.
123.7 An injured claimant may, when the claimant is first injured, select a non-panel physician to provide medical services, appliances, and supplies if the claimant is unable to make an appointment with a panel physician due to the urgency of the need for treatment.
123.8If there is a need for immediate medical treatment and, due to the nature of an injury, the injured claimant is unable to contact a physician, the injured claimant may seek treatment at an emergency care facility. Notice of the provision of emergency care shall be provided to the Program no later than thirty (30) days after the care is rendered.
123.9 Once a panel treating physician is selected to provide treatment under the Act, an injured claimant shall not change to another physician or hospital without authorization of the Program, except in an emergency.
123.10 If the injured claimant is not satisfied with the medical care provided by a panel physician, a request for change shall be submitted, in writing, with justification to the Program. The Program shall permit a change where the Program finds the change to be in the best interest of the injured claimant.
123.11Upon a request from the Program, the claimant and panel or non-panel treating physicians shall provide copies of all the claimant’s medical records regardless of the source of the record(s) or the medical condition(s) addressed in the records. The Program shall take appropriate steps to ensure that the medical records provided to it are maintained in a confidential manner.
123.12 After the claimant’s first appointment with a treating physician, the physician shall file a comprehensive medical report with the Program containing a diagnosis of physical findings or examination, a statement concerning the injury’s relationship to employment, the treatment plan, if any, and an opinion regarding the claimant’s prognosis within ten (10) business days of an examination of the injured employee or claimant.
123.13The following information shall be included in a medical report from a physician that is used by the Program in connection with an ID, ED, or other Program decision affecting a claimant’s benefits:
(a) Date(s) of examination and treatment, if any;
(b) History given by the claimant;
(c) Physical findings;
(d) Results of diagnostic tests;
(e) Diagnosis;
(f) Course of treatment, if any;
(g) Description of any other conditions found that are not due to the claimed injury;
(h) Treatment given or recommended for the claimed injury, if any;
(i) Physician's opinion, with medical reasons, as to causal relationship between the diagnosed condition(s) and the factors or conditions of the employment;
(j) Extent of disability affecting the claimant’s ability to work due to the injury;
(k) Prognosis for recovery, including an estimate regarding when the claimant will be able to return to work; and
(l) All other material findings.
123.14 Any physician who continues to treat an injured employee or claimant shall, at no cost, provide periodic progress reports, treatment records, and bills to the Program, in compliance with § 123.12.
123.15 The Program may require an injured claimant to submit to physical examinations at times and places reasonably convenient for the claimant in order to continue to investigate a claimant’s eligibility for benefits under the Act. The Program may suspend a claimant’s benefits if the claimant fails to attend or otherwise obstructs a physical examination that is required by the Program.
123.16If the Program denies authorization for payment for any treatment or procedure, the Program shall provide a claimant with written notice of the denial, using a form that the Program creates, no later than thirty (30) days after the treating physician makes a written request to the Program for this authorization.
123.17If the Program fails to provide written notification to the claimant within thirty (30) days of the request, it shall be deemed that the Program authorized the treatment or procedure, unless the Program commences a utilization review pursuant to § 126 of this chapter within thirty (30) days of the request.
123.18If a claimant or treating physician is unsatisfied with a decision of the Program under this subsection, the claimant or physician may make a written request that the Program initiate the utilization review process pursuant to § 126 of this chapter within thirty (30) days of receipt of the Program’s decision.
123.19 All medical providers shall include in each medical report and bill for services rendered under the Act, the code, as published by the American Medical Association (AMA) in the most current edition of the Physicians Current Procedural Terminology (CPT Codes), for detailing the billing of all medical procedures and the codes established by the most recent edition of the International Classification of Diagnosis (ICD) code, as published by the U.S. Department of Health and Human Services, for diagnosing the conditions.
123.20 The Program shall require a medical report and/or invoice from a medical care provider to substantiate payment of bills. All reports shall be typewritten on the physician's letterhead and signed and dated by the attending physician.
123.21 Fees and other charges for treatment or medical services shall be limited to those that are reasonable and customary charges prevailing in the local medical community as the Program determines.
123.22 The cost of physical examinations ordered by the Program shall be paid by the Program, unless the examination is conducted by a non-panel physician. A panel physician shall not attempt to collect a disputed payment for medical services in connection with a compensable claim under the Act from the injured employee or claimant.