(a) An employee shall submit to examination by a medical officer of the District of Columbia government, or by a physician designated or approved by the Mayor, after the injury and as frequently and at the times and places as may be reasonably required. The employee may have a physician designated and paid by him or her present to participate in the examination.

(a-1) Each person who provides medical care or service under this subchapter shall utilize a standard coding system for reports and bills pursuant to regulations prescribed by the Mayor.

(a-2) Any medical care or service furnished or scheduled to be furnished under this subchapter shall be subject to utilization review. Utilization review may be accomplished prospectively, concurrently, or retrospectively. A decision on the medical care or service to the employee shall be made by the utilization review organization or individual within 60 days after the utilization review is requested. If the utilization review is not completed within 120 days of the request, the care or service under review shall be deemed approved. If the Mayor denies medical care or service because the medical care provider or claimant has not provided enough information for the utilization review process, the provider or claimant may request approval for the medical care or service again by providing new information.

(1) In order to determine the necessity, character, or sufficiency of any medical care or service furnished or scheduled to be furnished under this subchapter and to allow for the performance of competent utilization review, a utilization review organization or individual used pursuant to this chapter shall be certified by the Utilization Review Accreditation Commission.

(2) When it appears that the necessity, character, or sufficiency of medical care or service to an employee is improper or that medical care or service scheduled to be furnished must be clarified, the Mayor, employee, or District of Columbia government may initiate review by a utilization review organization or individual.

(3) If the medical care provider or employee disagrees with the opinion of the utilization review organization or individual, the medical care provider, or employee shall have the right to request reconsideration of the opinion by the utilization review organization or individual 60 calendar days from receipt of the utilization review report. The request for reconsideration shall be written and contain reasonable medical justification for the reconsideration.

(4) Disputes between a medical care provider, employee, or District of Columbia government on the issue of necessity, character, or sufficiency of the medical care or service furnished, or scheduled to be furnished, or the fees charged by the medical care provider shall be resolved by the Mayor upon application for a hearing by the District of Columbia government, employee, or medical provider. The decision of the Mayor may be reviewed by the Superior Court of the District of Columbia. The decision may be affirmed, modified, revised, or remanded in the discretion of the court. The decision shall be affirmed if supported by substantial competent evidence on the record.

(5) The District of Columbia government shall pay the cost of a utilization review if the employee seeks the review and is the prevailing party.

(a-3) Medical care providers shall not hold employees liable for services rendered in connection with a compensable injury under this subchapter.

(b) An employee is entitled to be paid expenses incident to an examination required by the Mayor which, in the opinion of the Mayor, are necessary and reasonable, including transportation and loss of wages incurred in order to be examined. The expenses, when authorized or approved by the Mayor, are paid from the Employees’ Compensation Fund.

(c) The Mayor shall fix the fees for examinations under this section by physicians not employed by or under contract to the District of Columbia government to furnish medical services to employees. The fees, when authorized or approved by the Mayor, are paid from the Employees’ Compensation Fund.

(d) If an employee refuses to submit to or obstructs an examination, his or her right to compensation under this subchapter is suspended until the refusal or obstruction stops. Compensation is not payable while a refusal or obstruction continues, and the period of the refusal or obstruction is deducted from the period for which compensation is payable to the employee.

(Mar. 3, 1979, D.C. Law 2-139, § 2323, 25 DCR 5740; Mar. 6, 1991, D.C. Law 8-198, § 3(d), 37 DCR 6890; Apr. 5, 2005, D.C. Law 15-290, § 2(d), 52 DCR 1449; Sept. 24, 2010, D.C. Law 18-223, § 1062(b)(13), 57 DCR 6242; Sept. 20, 2012, D.C. Law 19-168, § 1122(b), 59 DCR 8025.)

1981 Ed., § 1-624.23.

1973 Ed., § 1-353.23.

This section is referenced in § 1-623.03.

D.C. Law 15-290, in subsec. (a-2), inserted “A decision on the medical care or service to the employee shall be made by the utilization review organization or individual within 60 days after the utilization review is requested. If the utilization review is not completed within 120 days of the request, the care or service under review shall be deemed approved. If the Mayor denies medical care or service because the medical care provider or claimant has not provided enough information for the utilization review process, the provider or claimant may request approval for the medical care or service again by providing new information.” at the end of the second lead-in sentence, inserted “or employee” following “If the medical care provider” and inserted “, or employee” following “individual, the medical care provider” in par. (3), and inserted “In all medical opinions used under this section, the diagnosis or medical opinion of the employee’s treating physician shall be accorded great weight over other opinions, absent compelling reasons to the contrary.” in par. (4).

D.C. Law 18-223, in subsec. (a-2)(4), deleted “In all medical opinions used under this section, the diagnosis or medical opinion of the employee’s treating physician shall be accorded great weight over other opinions, absent compelling reasons to the contrary.”

The 2012 amendment by D.C. Law 19-168 would have added the last sentence in (a-2)(4).

For temporary (90 day) amendment of section, see § 1062(b)(13) of Fiscal Year 2011 Budget Support Emergency Act of 2010 (D.C. Act 18-463, July 2, 2010, 57 DCR 6542).

Mayor authorized to issue rules: See Historical and Statutory Notes following § 1-623.01.

Section 1122(b) of D.C. Law 19-168 would have added a sentence in (a-2)(4) to read as follows: “In all medical opinions used under this section, the diagnosis or medical opinion of the employee’s treating physician shall be accorded great weight over other opinions, absent compelling reasons to the contrary.”

Applicability of D.C. Law 19-168: Section 1123 of D.C. Law 19-168 provided that subtitle L of the act (§§ 1121 to 1123) shall apply upon certification by the Chief Financial Officer that sufficient revenue is available in the June 2012, September 2012, or December 2012 revenue estimates to fund section 10002(a)(1) through (29) of the Revised Revenue Estimate Contingency Priority List Act of 2012, passed on 2nd reading on June 5, 2012 (Enrolled version of Bill 19-743).

Applicability of D.C. Law 19-168: The Budget Office of the District of Columbia Council has determined that the conditions of § 1123 of D.C. Law 19-168 were not met. Therefore the amendments to this section by section 1122(a) of D.C. Law 19-168 have not been given effect.