| (a) Definition. A disqualifying association is any
association that may reasonably be perceived as having potential to
influence the conduct or decision of a designated doctor. Disqualifying
associations may include:
(1) receipt of income, compensation, or payment of
any kind not related to health care the doctor provides;
(2) shared investment or ownership interest;
(3) contracts or agreements that provide incentives,
such as referral fees, payments based on volume or value, and waiver
of beneficiary coinsurance and deductible amounts;
(4) contracts or agreements for space or equipment
rentals, personnel services, management contracts, referral services,
billing services agents, documentation management or storage services
or warranties, or any other services related to managing or operating
the doctor's practice;
(5) personal or family relationships;
(6) a contract with the same workers' compensation
health care network certified under Insurance Code Chapter 1305 or
a contract with the same political subdivision or political subdivision
health plan under Labor Code §504.053(b)(2) that is responsible
for providing medical benefits to the injured employee; or
(7) any other financial arrangement that would require
disclosure under the Labor Code, the Insurance Code, or applicable
rules, or any other association with the injured employee, the employer,
or insurance carrier that may give the appearance of preventing the
designated doctor from rendering an unbiased opinion.
(b) Disqualification of agent. A designated doctor
also has a disqualifying association relevant to an examination or
claim if an agent of the designated doctor has an association relevant
to the claim that would constitute a disqualifying association under
subsection (a) of this section.
(c) Prohibition. A designated doctor must not perform
an examination if that doctor has a disqualifying association relevant
to that claim.
(1) If a designated doctor learns of a disqualifying
association relevant to a claim after accepting the examination, the
designated doctor must notify the division of that disqualifying association
within two working days of learning of the disqualifying association.
(2) A designated doctor who performs an examination
even though the doctor has a disqualifying association relevant to
that claim commits an administrative violation.
(d) Notice required. Within five days of receiving
the division's order of designated doctor examination under §127.5(b)
of this title (relating to Scheduling Designated Doctor Appointments),
insurance carriers must notify the division of any disqualifying associations
between the designated doctor and injured employee because of the
network affiliations described under subsection (a)(6) of this section.
(e) Effect of disqualifying association. If the division
determines that a designated doctor with a disqualifying association
performed a designated doctor examination, all reports produced by
that designated doctor as a result of that examination are stripped
of their presumptive weight.
(f) Disputes about disqualifying associations. A party
that seeks to dispute the selection of a designated doctor for a particular
examination based on a disqualifying association or dispute the presumptive
weight of a designated doctor's report based on a disqualifying association
must do so through the division's dispute resolution processes in
Labor Code Chapter 410 and Chapters 140-144 and 147 of this title
(relating to dispute resolution processes, proceedings, and procedures).
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| Source Note: The provisions of this §127.140 adopted to be effective September 1, 2012, 37 TexReg 5422; amended to be effective November 4, 2018, 43 TexReg 7149; amended to be effective April 30, 2023, 48 TexReg 2123 |
