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U.S. Code as of:
01/19/04
Section 907. Medical services and supplies
(a) General requirement
The employer shall furnish such medical, surgical, and other
attendance or treatment, nurse and hospital service, medicine,
crutches, and apparatus, for such period as the nature of the
injury or the process of recovery may require.
(b) Physician selection; administrative supervision; change of
physicians and hospitals
The employee shall have the right to choose an attending
physician authorized by the Secretary to provide medical care under
this chapter as hereinafter provided. If, due to the nature of the
injury, the employee is unable to select his physician and the
nature of the injury requires immediate medical treatment and care,
the employer shall select a physician for him. The Secretary shall
actively supervise the medical care rendered to injured employees,
shall require periodic reports as to the medical care being
rendered to injured employees, shall have authority to determine
the necessity, character, and sufficiency of any medical aid
furnished or to be furnished, and may, on his own initiative or at
the request of the employer, order a change of physicians or
hospitals when in his judgment such change is desirable or
necessary in the interest of the employee or where the charges
exceed those prevailing within the community for the same or
similar services or exceed the provider's customary charges. Change
of physicians at the request of employees shall be permitted in
accordance with regulations of the Secretary.
(c) Physicians and health care providers not authorized to render
medical care or provide medical services
(1)(A) The Secretary shall annually prepare a list of physicians
and health care providers in each compensation district who are not
authorized to render medical care or provide medical services under
this chapter. The names of physicians and health care providers
contained on the list required under this subparagraph shall be
made available to employees and employers in each compensation
district through posting and in such other forms as the Secretary
may prescribe.
(B) Physicians and health care providers shall be included on the
list of those not authorized to provide medical care and medical
services pursuant to subparagraph (A) when the Secretary determines
under this section, in accordance with the procedures provided in
subsection (j) of this section, that such physician or health care
provider -
(i) has knowingly and willfully made, or caused to be made, any
false statement or misrepresentation of a material fact for use
in a claim for compensation or claim for reimbursement of medical
expenses under this chapter;
(ii) has knowingly and willfully submitted, or caused to be
submitted, a bill or request for payment under this chapter
containing a charge which the Secretary finds to be substantially
in excess of the charge for the service, appliance, or supply
prevailing within the community or in excess of the provider's
customary charges, unless the Secretary finds there is good cause
for the bill or request containing the charge;
(iii) has knowingly and willfully furnished a service,
appliance, or supply which is determined by the Secretary to be
substantially in excess of the need of the recipient thereof or
to be of a quality which substantially fails to meet
professionally recognized standards;
(iv) has been convicted under any criminal statute (without
regard to pending appeal thereof) for fraudulent activities in
connection with any Federal or State program for which payments
are made to physicians or providers of similar services,
appliances, or supplies; or
(v) has otherwise been excluded from participation in such
program.
(C) Medical services provided by physicians or health care
providers who are named on the list published by the Secretary
pursuant to subparagraph (A) of this section shall not be
reimbursable under this chapter; except that the Secretary shall
direct the reimbursement of medical claims for services rendered by
such physicians or health care providers in cases where the
services were rendered in an emergency.
(D) A determination under subparagraph (B) shall remain in effect
for a period of not less than three years and until the Secretary
finds and gives notice to the public that there is reasonable
assurance that the basis for the determination will not reoccur.
(E) A provider of a service, appliance, or supply shall provide
to the Secretary such information and certification as the
Secretary may require to assure that this subsection is enforced.
(2) Whenever the employer or carrier acquires knowledge of the
employee's injury, through written notice or otherwise as
prescribed by the chapter, the employer or carrier shall forthwith
authorize medical treatment and care from a physician selected by
an employee pursuant to subsection (b) of this section. An employee
may not select a physician who is on the list required by paragraph
(1) of this subsection. An employee may not change physicians after
his initial choice unless the employer, carrier, or deputy
commissioner has given prior consent for such change. Such consent
shall be given in cases where an employee's initial choice was not
of a specialist whose services are necessary for and appropriate to
the proper care and treatment of the compensable injury or disease.
In all other cases, consent may be given upon a showing of good
cause for change.
(d) Request of treatment or services prerequisite to recovery of
expenses; formal report of injury and treatment; suspension of
compensation for refusal of treatment or examination;
justification
(1) An employee shall not be entitled to recover any amount
expended by him for medical or other treatment or services unless -
(A) the employer shall have refused or neglected a request to
furnish such services and the employee has complied with
subsections (b) and (c) of this section and the applicable
regulations; or
(B) the nature of the injury required such treatment and
services and the employer or his superintendent or foreman having
knowledge of such injury shall have neglected to provide or
authorize same.
(2) No claim for medical or surgical treatment shall be valid and
enforceable against such employer unless, within ten days following
the first treatment, the physician giving such treatment furnishes
to the employer and the deputy commissioner a report of such injury
or treatment, on a form prescribed by the Secretary. The Secretary
may excuse the failure to furnish such report within the ten-day
period whenever he finds it to be in the interest of justice to do
so.
(3) The Secretary may, upon application by a party in interest,
make an award for the reasonable value of such medical or surgical
treatment so obtained by the employee.
(4) If at any time the employee unreasonably refuses to submit to
medical or surgical treatment, or to an examination by a physician
selected by the employer, the Secretary or administrative law judge
may, by order, suspend the payment of further compensation during
such time as such refusal continues, and no compensation shall be
paid at any time during the period of such suspension, unless the
circumstances justified the refusal.
(e) Physical examination; medical questions; report of physical
impairment; review or reexamination; costs
In the event that medical questions are raised in any case, the
Secretary shall have the power to cause the employee to be examined
by a physician employed or selected by the Secretary and to obtain
from such physician a report containing his estimate of the
employee's physical impairment and such other information as may be
appropriate. Any party who is dissatisfied with such report may
request a review or reexamination of the employee by one or more
different physicians employed or selected by the Secretary. The
Secretary shall order such review or reexamination unless he finds
that it is clearly unwarranted. Such review or reexamination shall
be completed within two weeks from the date ordered unless the
Secretary finds that because of extraordinary circumstances a
longer period is required. The Secretary shall have the power in
his discretion to charge the cost of examination or review under
this subsection to the employer, if he is a self-insurer, or to the
insurance company which is carrying the risk, in appropriate cases,
or to the special fund in section 944 of this title.
(f) Place of examination; exclusion of physicians other than
examining physician of Secretary; good cause for conclusions of
other physicians respecting impairment; examination by employer's
physician; suspension of proceedings and compensation for refusal
of examination
An employee shall submit to a physical examination under
subsection (e) of this section at such place as the Secretary may
require. The place, or places, shall be designated by the Secretary
and shall be reasonably convenient for the employee. No physician
selected by the employer, carrier, or employee shall be present at
or participate in any manner in such examination, nor shall
conclusions of such physicians as to the nature or extent of
impairment or the cause of impairment be available to the examining
physician unless otherwise ordered, for good cause, by the
Secretary. Such employer or carrier shall, upon request, be
entitled to have the employee examined immediately thereafter and
upon the same premises by a qualified physician or physicians in
the presence of such physician as the employee may select, if any.
Proceedings shall be suspended and no compensation shall be payable
for any period during which the employee may refuse to submit to
examination.
(g) Fees and charges for examinations, treatment, or service;
limitation; regulations
All fees and other charges for medical examinations, treatment,
or service shall be limited to such charges as prevail in the
community for such treatment, and shall be subject to regulation by
the Secretary. The Secretary shall issue regulations limiting the
nature and extent of medical expenses chargeable against the
employer without authorization by the employer or the Secretary.
(h) Third party liability
The liability of an employer for medical treatment as herein
provided shall not be affected by the fact that his employee was
injured through the fault or negligence of a third party not in the
same employ, or that suit has been brought against such third
party. The employer shall, however, have a cause of action against
such third party to recover any amounts paid by him for such
medical treatment in like manner as provided in section 933(b) of
this title.
(i) Physicians' ineligibility for subsection (e) physical
examinations and reviews because of workmen's compensation claim
employment or fee acceptance or participation
Unless the parties to the claim agree, the Secretary shall not
employ or select any physician for the purpose of making
examinations or reviews under subsection (e) of this section who,
during such employment, or during the period of two years prior to
such employment, has been employed by, or accepted or participated
in any fee relating to a workmen's compensation claim from any
insurance carrier or any self-insurer.
(j) Procedure; judicial review
(1) The Secretary shall have the authority to make rules and
regulations and to establish procedures, not inconsistent with the
provisions of this chapter, which are necessary or appropriate to
carry out the provisions of subsection (c) of this section,
including the nature and extent of the proof and evidence necessary
for actions under this section and the methods of taking and
furnishing such proof and evidence.
(2) Any decision to take action with respect to a physician or
health care provider under this section shall be based on specific
findings of fact by the Secretary. The Secretary shall provide
notice of these findings and an opportunity for a hearing pursuant
to section 556 of title 5 for a provider who would be affected by a
decision under this section. A request for a hearing must be filed
with the Secretary within thirty days after notice of the findings
is received by the provider making such request. If a hearing is
held, the Secretary shall, on the basis of evidence adduced at the
hearing, affirm, modify, or reverse the findings of fact and
proposed action under this section.
(3) For the purpose of any hearing, investigation, or other
proceeding authorized or directed under this section, the
provisions of section (!1) 49 and 50 of title 15 (relating to the
attendance of witnesses and the production of books, papers, and
documents) shall apply to the jurisdiction, powers, and duties of
the Secretary or any officer designated by him.
(4) Any physician or health care provider, after any final
decision of the Secretary made after a hearing to which he was a
party, irrespective of the amount in controversy, may obtain a
review of such decision by a civil action commenced within sixty
days after the mailing to him of notice of such decision, but the
pendency of such review shall not operate as a stay upon the effect
of such decision. Such action shall be brought in the court of
appeals of the United States for the judicial circuit in which the
plaintiff resides or has his principal place of business, or the
Court of Appeals for the District of Columbia. As part of his
answer, the Secretary shall file a certified copy of the transcript
of the record of the hearing, including all evidence submitted in
connection therewith. The findings of fact of the Secretary, if
based on substantial evidence in the record as a whole, shall be
conclusive.
(k) Refusal of treatment on religious grounds
(1) Nothing in this chapter prevents an employee whose injury or
disability has been established under this chapter from relying in
good faith on treatment by prayer or spiritual means alone, in
accordance with the tenets and practice of a recognized church or
religious denomination, by an accredited practitioner of such
recognized church or religious denomination, and on nursing
services rendered in accordance with such tenets and practice,
without suffering loss or diminution of the compensation or
benefits under this chapter. Nothing in this subsection shall be
construed to except an employee from all physical examinations
required by this chapter.
(2) If an employee refuses to submit to medical or surgical
services solely because, in adherence to the tenets and practice of
a recognized church or religious denomination, the employee relies
upon prayer or spiritual means alone for healing, such employee
shall not be considered to have unreasonably refused medical or
surgical treatment under subsection (d) of this section.
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