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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 7-124. ADDITIONAL MEDICAL EXAMINATIONS
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124.1 The Program may require a claimant who has filed a claim for benefits or who is receiving benefits to participate in an Additional Medical Examination (AME) with a physician selected by the Program.
124.2The Program shall maintain a list of AME physicians. AME physicians shall have expertise and board certification in various specialties that are consistent with claimants’ most common injuries, as determined by the Program. AME physicians shall be selected on the basis of several factors, including:
(a) Experience in their field;
(b) Experience with and understanding of workers’ compensation procedures and guidelines;
(c) Reputation for honesty and integrity;
(d) Positive records with licensing boards; and
(e) Availability to provide timely appointments, reports, depositions, and court appearances.
124.3 AME physicians may be added to and removed from the Program’s list of AME physicians at the discretion of the Program.
124.4An AME shall consist of a case file review, and/or an in-person assessment or examination, by a qualified health professional other than the treating physician.
124.5 The Program may schedule an AME when:
(a) Diagnosis does not match the claim;
(b) The duration of claimant’s inability to work is longer than generally accepted guidelines allow for that particular injury, including the Official Disability Guidelines published by the Work Loss Data Institute, or similar guidelines;
(c) Surgery is recommended;
(d) There is a question regarding the underlying accuracy or consistency of the opinion of the treating physician; or
(e) There is any reason to verify that the treatment or care provided is appropriate, adequate and solely for the injury incurred in the performance of the employee’s duty.
124.6The Program shall inform a claimant in writing of the requirement that he or she attend an AME appointment, and that failure to attend the appointment, failure to bring medical records under the claimant’s possession and control, or any other obstruction of the examination, may result in a suspension of the employee’s benefits.
124.7If the claimant does not attend the AME appointment, fails to bring medical records under the claimant’s possession and control, or otherwise obstructs the examination, the Program may suspend the claimant’s benefits.
124.8If the Program suspends benefits pursuant to this section, it shall issue a NOD to the claimant informing him or her of the suspension and how the claimant can have his or her benefits reinstated.
124.9If the claimant attends a newly scheduled appointment, provides requested records, or otherwise cooperates with the examination as directed by the Program, the claimant’s benefits shall be reinstated as of the date of compliance. The date of compliance is the date the claimant attends the newly scheduled appointment, the date the Program receives requested records, or the date the claimant otherwise cooperates with the examination as directed by the Program.
124.10 An AME report shall be conclusive and responsive to the requests from the Program as part of a complete professional evaluation and shall comply with the requirements of §§ 123.12, 123.13, and 123.20.
124.11Prior to any determination of coverage based upon an AME’s recommendation(s), the claimant’s treating physician shall have thirty (30) days from receipt of a copy of the AME to submit written comments to the Program regarding the AME finding(s). If an employee or claimant has not treated with a treating physician for his or her injury for one (1) year or more, the Program does not have to share a copy of the AME’s recommendation with the claimant’s treating physician.