20 C.F.R. § 702.413

Fees for medical services; prevailing community charges

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All fees charged by medical care providers for persons covered by this Act shall be limited to such charges for the same or similar care (including supplies) as prevails in the community in which the medical care provider is located and shall not exceed the customary charges of the medical care provider for the same or similar services. Where a dispute arises concerning the amount of a medical bill, the Director shall determine the prevailing community rate using the OWCP Medical Fee Schedule (as described in 20 CFR 10.805 through 10.810) to the extent appropriate, and where not appropriate, may use other state or federal fee schedules. The opinion of the Director that a charge by a medical care provider disputed under the provisions of section 702.414 exceeds the charge which prevails in the community in which said medical care provider is located shall constitute sufficient evidence to warrant further proceedings pursuant to section 702.414 and to permit the Director to direct the claimant to select another medical provider for care to the claimant.

[60 FR 51348, Oct. 2, 1995, as amended at 77 FR 37286, June 21, 2012]

Notes of Decisions

Cited in 5 cases, 1991–2019 · leading case: Newport News Shipbuilding & Dry Dock Co. v. Loxley, 934 F.2d 511 (4th Cir. 1991).

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Newport News Shipbuilding & Dry Dock Co. v. Loxley, 934 F.2d 511 (4th Cir. 1991). · cites it 9× “at § 907(g); 20 C.F.R. § 702.413 (1990). The Board also found that the survey of fees by NNS was “inherently flawed” because it did not distinguish on *515 the basis of medical specialization.”

Robert W. Hunt, M.D. v. Dir., Off. of Workers' Comp. Programs, U.S. Dep't of Labor Marine Terminals Corp., 999 F.2d 419 (9th Cir. 1993). “The Board erred. Bjazevich had no particular incentive to prove that Hunt and DiPalma’s charges were “prevailing community charges” as required by § 7(g) of the Act and 20 C.”

Terry Grimm v. Vortex Marine Constr., 921 F.3d 845 (9th Cir. 2019). “See 20 C.F.R. § 702.413 (requiring the agency to determine the reasonableness of disputed fees).”

St. Mary's Reg'l Med. Ctr. v. Bath Iron Works, 2009 ME 92 (Me. 2009). “407 (b) (2009) (providing that the Director of OWCP is responsible for determining whether charges for medical care exceed those permitted by the Act); 20 C.F.R. § 702.413 (2009) (providing that the Director of OWCP decides prevailing rate in the community using federal fee…”

La Ins Guar. Asso v. Parker (5th Cir. 2002). “See 20 C.F.R. §§ 702.413 – 702.417 (2001). V.”

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