(a) The Director may, upon written complaint of an interested party,
or upon the Director's own initiative, investigate any medical care
provider or any fee for medical treatment, services, or supplies that
appears to exceed prevailing community charges for similar treatment,
services or supplies or the provider's customary charges. The OWCP
medical fee schedule (see section 702.413) shall be used by the
Director, where appropriate, to determine the prevailing community
charges for a medical procedure by a physician or hospital (to the
extent such procedure is covered by the OWCP fee schedule). The
Director's investigation may initially be conducted informally through
contact of the medical care provider by the district director. If this
informal investigation is unsuccessful further proceedings may be
undertaken. These proceedings may include, but not be limited to: an
informal conference involving all interested parties; agency
interrogatories to the pertinent medical care provider; and issuance of
subpoenas duces tecum for documents having a bearing on the dispute.
(1) A claim by the provider that the OWCP fee schedule does not
represent the prevailing community rate will be considered only where
the following circumstances are presented:
(i) where the actual procedure performed was incorrectly identified
by medical procedure code;
(ii) that the presence of a severe or concomitant medical condition
made treatment especially difficult;
(iii) the provider possessed unusual qualifications (board
certification in a specialty is not sufficient evidence in itself of
unusual qualifications); or
(iv) the provider or service is not one covered by the OWCP fee
schedule as described by 20 CFR 10.411(d)(1).
(2) The circumstances listed in paragraph (a)(1) of this section are
the only ones which will justify reevaluation of the amount calculated
under the OWCP fee schedule.
(b) The failure of any medical care provider to present any evidence
required by the Director pursuant to this section without good cause
shall not prevent the Director from making findings of fact.
(c) After any proceeding under this section the Director shall make
specific findings on whether the fee exceeded the prevailing community
charges (as established by the OWCP fee schedule, where appropriate) or
the provider's customary charges and provide notice of these findings to
the affected parties.
(d) The Director may suspend any such proceedings if after receipt
of the written complaint the affected parties agree to withdraw the
controversy from agency consideration on the basis that such controversy
has been resolved by the affected parties. Such suspension, however,
shall be at the discretion of the Director.
[51 FR 4286, Feb. 3, 1986, as amended at 60 FR 51348, Oct. 2, 1995]
