Report Title:

Work Comp

Description:

Authorizes employers to establish medical provider networks to provide medical treatment to injured workers.

HOUSE OF REPRESENTATIVES

H.B. NO.

1600

TWENTY-THIRD LEGISLATURE, 2005

 

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. Chapter 386, Hawaii Revised Statutes, is amended by adding four new sections to be appropriately designated and to read as follows:

"§386- Medical provider networks. (a) On or after January 1, 2006, an insurer or self-insured employer may establish or modify a medical provider network for the provision of medical treatment to injured employees.

(b) The network shall include physicians primarily engaged in the treatment of occupational injuries and physicians primarily engaged in the treatment of nonoccupational injuries. The goal shall be at least twenty-five per cent of physicians primarily engaged in the treatment of nonoccupational injuries. The director shall encourage the integration of occupational and nonoccupational providers. The number of physicians in the medical provider network shall enable treatment for injuries or conditions to be provided in a timely manner. The provider network shall include physicians and other providers to treat common injuries experienced by injured employees based on the type of occupation or industry in which the employee is engaged.

(c) Medical treatment for injuries shall be readily available at reasonable times to all employees. To the extent feasible, all medical treatment for injuries shall be readily accessible to all employees. With respect to availability and accessibility of treatment, the director shall consider the needs of rural areas, specifically those in which health facilities are located at least thirty miles apart.

(d) The self-insured employer or insurer shall submit a plan for the medical provider network to the director for approval. The director shall approve the plan if it is determined that the plan meets the requirements of this section. If the director does not act on the plan within sixty days of receiving the plan, it shall be deemed approved.

(e) Physician compensation may not be structured in order to achieve the goal of reducing, delaying, or denying medical treatment or restricting access to medical treatment.

(f) If the self-insured employer or insurer meets the requirements of this section, the director may not withhold approval or disapprove a self-insured employer's or insurer's medical provider network based solely on the selection of providers. In developing a medical provider network, a self-insured employer or insurer shall have the exclusive right to determine the members of the network.

(g) All physicians and other providers within the medical provider network shall be subject to the requirements of the rules of the department of labor and industrial relations implementing the workers' compensation medical fee schedule.

(h) No person other than a licensed physician who is competent to evaluate the specific clinical issues involved in the medical treatment services, when these services are within the scope of the physician's practice, may modify, delay, or deny requests for authorization of medical treatment.

(i) On or before November 1, 2005, the director shall adopt rules under chapter 91, implementing this section the rules shall be exempt from the public notice and public hearing requirements of chapter 91. The director shall develop rules that establish procedures for purposes of making medical provider network modifications.

§386- Economic profile filing. (a) An insurer or self-insured employer that offers a medical provider network under this section and that uses economic profiling shall file with the director a description of any policies and procedures related to economic profiling utilized by the insurer or self-insured employer. The filing shall describe how these policies and procedures are used in utilization review, peer review, incentive and penalty programs, and in provider retention and termination decisions. The insurer or self-insured employer shall provide a copy of the filing to an individual physician, provider, medical group, or individual practice association.

(b) The director shall make each insurer's or self-insured employer's filing available to the public upon request. The director may not publicly disclose any information submitted pursuant to this section that is determined by the director to be confidential pursuant to state or federal law.

(c) For purposes of this section, "economic profiling" shall mean any evaluation of a particular physician, provider, medical group, or individual practice association based in whole or in part on the economic costs or utilization of services associated with medical care provided or authorized by the physician, provider, medical group, or individual practice association.

§386- Continuity of care. (a) An insurer or self-insured employer that arranges for care for injured employees through a medical provider network shall file a written continuity of care policy with the director.

(b) If approved by the director, the provisions of the written continuity of care policy shall replace all prior continuity of care policies. The insurer or self-insured employer shall file a revision of the continuity of care policy with the director if it makes a material change to the policy.

(c) The insurer or self-insured employer shall provide to all employees entering the workers' compensation system notice of its written continuity of care policy and information regarding the process for an employee to request a review under the policy and shall provide, upon request, a copy of the written policy to an employee.

(d) An insurer or self-insured employer that offers a medical provider network, at the request of an injured employee, shall provide the completion of treatment as set forth in this section by a terminated provider.

(e) The completion of treatment shall be provided by a terminated provider to an injured employee who, at the time of the contract's termination, was receiving services from that provider for one of the conditions described in subsection (f).

(f) The insurer or self-insured employer shall provide for the completion of treatment for the following conditions subject to coverage through the workers' compensation system:

(1) An acute condition. An acute condition is a medical condition that involves a sudden onset of symptoms due to an illness, injury, or other medical problem that requires prompt medical attention and that has a limited duration. Completion of treatment shall be provided for the duration of the acute condition;

(2) A serious chronic condition. A serious chronic condition is a medical condition due to a disease, illness, or other medical problem or medical disorder that is serious in nature and that persists without full cure or worsens over an extended period of time or requires ongoing treatment to maintain remission or prevent deterioration. Completion of treatment shall be provided for a period of time necessary to complete a course of treatment and to arrange for a safe transfer to another provider, as determined by the insurer or self-insured employer in consultation with the injured employee and the terminated provider and consistent with good professional practice. Completion of treatment shall not exceed twelve months from the contract termination date;

(3) A terminal illness. A terminal illness is an incurable or irreversible condition that has a high probability of causing death within one year or less. Completion of treatment shall be provided for the duration of a terminal illness; or

(4) Performance of a surgery or other procedure that is authorized by the insurer or self-insured employer as part of a documented course of treatment and has been recommended and documented by the provider to occur within one hundred and eighty days of the contract's termination date.

(g) The insurer or self-insured employer may require the terminated provider whose services are continued beyond the contract termination date pursuant to this subsection to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider prior to termination.

If the terminated provider does not agree to comply or does not comply with these contractual terms and conditions, the insurer or self-insured employer is not required to continue the provider's services beyond the contract termination date.

Unless otherwise agreed by the terminated provider and the insurer or self-insured employer, the services rendered pursuant to this subsection shall be compensated at rates and methods of payment similar to those used by the insurer or self-insured employer for currently contracting providers providing similar services who are practicing in the same or a similar geographic area as the terminated provider. The insurer or provider is not required to continue the services of a terminated provider if the provider does not accept the payment rates provided for in this subsection.

(h) An insurer or self-insured employer shall ensure that the requirements of this section are met.

(i) This section shall not require an insurer or self-insured employer to provide for completion of treatment by a provider whose contract with the insurer or self-insured employer has been terminated or not renewed for reasons relating to a medical disciplinary cause or reason, or fraud or other criminal activity.

(j) Nothing in this section shall preclude an insurer or self-insured employer from providing continuity of care beyond the requirements of this section.

(k) The insurer or self-insured employer may require the terminated provider whose services are continued beyond the contract termination date pursuant to this section to agree in writing to be subject to the same contractual terms and conditions that were imposed upon the provider prior to termination. If the terminated provider does not agree to comply or does not comply with these contractual terms and conditions, the insurer or self-insured employer is not required to continue the provider's services beyond the contract termination date.

§386- Change of physician, surgeon, hospital, or rehabilitation facility. (a) In the event an injured employee elects to change attending physicians within the medical provider network, the employee shall notify the self-insured employer prior to initiating the change. The newly selected attending physician shall make a diligent effort to secure from the previous physician, or from the self-insured employer, all of the available medical information. The previous attending physician shall immediately forward, upon request, all requested information and x-rays to the new attending physician. Changes in the attending physician by the injured employee subsequent to the first change require prior approval by the director or self-insured employer.

(b) On the basis of competent medical advice, the director shall determine the need for or sufficiency of medical services furnished or to be furnished to the employee and may order any needed change of physician, surgeon, hospital, or rehabilitation facility. For the purposes of this section, "competent medical advice" may include advice from a panel of at least three physicians selected by the director after consultation with organizations such as the Hawaii Medical Association and convened for the purpose of this subsection. Fees for the panel of physicians selected by the director shall be paid from funds appropriated by the legislature for use by the department.

(c) Whenever the director determines medical reports submitted on an employee's industrial injury are not sufficiently complete to ascertain maximum medical recovery and to permit rendering a sound decision on the extent of disability suffered by the employee, the director shall refer the employee to another physician or surgeon for further examination and evaluation, at the expense of the self-insured employer.

(d) Whenever the director determines medical reports submitted on an employee's industrial injury are such that there may reasonably be diverse medical opinions on the extent of disability sustained by the employee (but for all other purposes the reports are complete), the director may appoint a duly qualified impartial physician or surgeon to examine the employee and reports. The fees for such examinations shall be paid from funds appropriated by the legislature for use by the department.

(e) Selection by the injured employee of a treating physician and any subsequent physicians shall be based on the physician's specialty or recognized expertise in treating the particular injury or condition in question.

(f) Treatment by a specialist who is not a member of the medical provider network may be permitted on a case-by-case basis if the medical provider network does not contain a physician who can provide the approved treatment and the treatment is approved by the employer or the insurer."

SECTION 2. Section 386-21, Hawaii Revised Statutes, is amended by amending subsection (b) to read as follows:

"(b) [Whenever] Unless a self-insured employer or the employer's insurer has established a medical provider network as provided in section 386- , whenever medical care is needed, 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."

SECTION 3. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored.

SECTION 4. This Act shall take effect upon its approval.

INTRODUCED BY:

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