Report Title:

Workers' compensation

Description:

Authorizes an injured employee to select any physician or surgeon to render care during the first 60 days after the injury is sustained. Authorize the Director of Labor and Industrial Relations, at the request of the employer, to seek competent medical advice from a panel of three physicians to determine the need for or sufficiency of medical services furnished or to be furnished. If, after consulting the panel, the director finds by a preponderance of the evidence that the employee's industrial injury is such that there is diverse medical opinions on the extent of disability sustained by the employee, the Director shall require the injured employee to select from an employer designated medical care provider list containing no less than three physicians or physician networks for the next 120 days of medical treatment. Provides that an injured employee whose injury poses significant permanent loss of a part or function of the body, or permanent and serious disfigurement shall retain the ability to select the physician or surgeon. Requires the application of all Medicare fee schedules, rather than just the Medicare Resource Based Relative Value Scale, apply to workers' compensation claims. (HB2660 HD1)

HOUSE OF REPRESENTATIVES

H.B. NO.

2660

TWENTY-SECOND LEGISLATURE, 2004

H.D. 1

STATE OF HAWAII

 


 

A BILL FOR AN ACT

 

relating to workers' compensation.

 

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

SECTION 1. Section 386-21, Hawaii Revised Statutes, is amended to read as follows:

"§386-21 Medical care, services, and supplies. (a) Immediately after a work injury sustained by an employee and so long as reasonably needed the employer shall furnish to the employee all medical care, services, and supplies as the nature of the injury requires. The liability of the medical care, services, and supplies shall be subject to the deductible under section 386-100.

(b) [Whenever] Except as otherwise provided in subsection (c), during the first sixty days after the injury is sustained and medical care is needed, and from the one hundred eighty-first day after the injury is sustained and thereafter, the injured employee may select any physician or surgeon who is practicing on the island where the injury was incurred to render such care. If the services of a specialist are indicated, the employee may select any such physician or surgeon practicing in the State.

The director may authorize the selection of a specialist practicing outside the State where no comparable medical attendance within the State is available. Upon procuring the services of such physician or surgeon, the injured employee shall give proper notice of the employee's selection to the employer within a reasonable time after the beginning of the treatment.

If for any reason during the period when medical care is needed, the employee wishes to change to another physician or surgeon, the employee may do so in accordance with rules prescribed by the director. If the employee is unable to select a physician or surgeon and the emergency nature of the injury requires immediate medical attendance, or if the employee does not desire to select a physician or surgeon and so advises the employer, the employer shall select the physician or surgeon. Such selection, however, shall not deprive the employee of the employee's right of subsequently selecting a physician or surgeon for continuance of needed medical care.

(c) On the sixtieth-first day after the injury is sustained, pursuant to a request by the employer, the director may seek competent medical advice to determine the need for or sufficiency of medical services furnished or to be furnished to the employee; provided that for purposes of this section, "competent medical advice" shall mean advice from a panel of at least three physicians selected by the director after consultation with a health maintenance organization as defined in section 432:1-104, or a mutual benefit society as defined in section 432D-1, and convened for the purposes of this subsection. After consulting with the panel, whenever the director determines by a preponderance of the evidence that the employee's industrial injury is such that there is diverse medical opinions on the extent of disability sustained by the employee, the director shall require the injured employee to select from an employer designated medical care provider list, which shall contain no less than three physicians as defined under chapters 453 and 460, or dentistry under chapter 448, or networks comprised of physicians as defined under chapters 453 and 460, or dentistry under chapter 448, to provide medical services for the next 120 days of medical treatment. In the absence of any employer designated medical care provider list, which must be furnished upon employment or prior to the date of injury, the injured employee may select any physician or surgeon (other than the physician or surgeon who treated the employer during the first sixty days after the injury was sustained) who is practicing on the island where the injury was incurred to render such care.

This subsection shall not apply to an injured employee whose injury poses either:

(1) Significant permanent loss of use of a part or function of the body; or

(2) Permanent and serious disfigurement;

provided that in the situations described in paragraphs 1 or 2, the employee may select any physician or surgeon who is practicing on the island where the injury was incurred to render such care; and provided further that if the services of a specialist is indicated, then the employee may select any such physician or surgeon practicing in the State.

[(c)](d) The liability of the employer for medical care, services, and supplies shall be limited to the charges computed as set forth in this section. The director shall make determinations of the charges and adopt fee schedules based upon those determinations. Effective January 1, 1997, and for each succeeding calendar year thereafter, the charges shall not exceed one hundred ten per cent of fees prescribed [in] by the Medicare [Resource Based Relative Value Scale] system applicable to Hawaii as [prepared] administered by the United States Department of Health and Human Services, except as provided in this subsection. The rates or fees provided for in this section shall be adequate to ensure at all times the standard of services and care intended by this chapter to injured employees.

If the director determines that an allowance under the medicare program is not reasonable, or if a medical treatment, accommodation, product, or service existing as of June 29, 1995, is not covered under the medicare program, the director may, at any time, establish an additional fee schedule or schedules not exceeding the prevalent charge for fees for services actually received by providers of health care services to cover charges for that treatment, accomodation, product, or service. If no prevalent charge for a fee for service has been established for a given service or procedure, the director shall adopt a reasonable rate that shall be the same for all providers of health care services to be paid for that service or procedure.

The director shall update the schedules required by this section every three years or annually, as required. The updates shall be based upon:

(1) Future charges or additions prescribed in the Medicare Resource Based Relative Value Scale system applicable to Hawaii as prepared by the United States Department of Health and Human Services; or

(2) A statistically valid survey by the director of prevalent charges for fees for services actually received by providers of health care services or based upon the information provided to the director by the appropriate state agency having access to prevalent charges for medical fee information.

When a dispute exists between an insurer or self-insured employer and a medical service provider regarding the amount of a fee for medical services, the director may resolve the dispute in a summary manner as the director may prescribe; provided that a provider shall not charge more than the provider's private patient charge for the service rendered.

[(d)](e) If it appears to the director that the injured employee has wilfully refused to accept the services of a competent physician or surgeon selected as provided in this section, or has wilfully obstructed the physician or surgeon, or medical, surgical, or hospital services or supplies, the director may consider such refusal or obstruction on the part of the injured employee to be a waiver in whole or in part of the right to medical care, services, and supplies, and may suspend the weekly benefit payments, if any, to which the employee is entitled so long as such refusal or obstruction continues.

[(e)](f) Such funds as are periodically necessary to the department to implement the foregoing provisions may be charged to and paid from the special compensation fund provided by section 386-151.

[(f)](g) In cases where the compensability of the claim is not contested by the employer, the medical services provider shall notify or bill the employer, insurer, or the special compensation fund for services rendered relating to the compensable injury within two years of the date services were rendered. Failure to bill the employer, insurer, or the special compensation fund within the two-year period shall result in the forfeiture of the medical service provider's right to payment. The medical service provider shall not directly charge the injured employee for treatment relating to the compensable injury."

SECTION 2. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored.

SECTION 3. This Act shall take effect upon its approval.