REPORT TITLE:
Insurance

DESCRIPTION:
Creates a uniform reference to the "workers' compensation
supplemental medical fee schedule."  Establishes a limitation on
the cost for an independent medical examination.  (HB2476 HD1)


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                        2476
HOUSE OF REPRESENTATIVES                H.B. NO.           H.D. 1
TWENTIETH LEGISLATURE, 2000                                
STATE OF HAWAII                                            
                                                             
________________________________________________________________
________________________________________________________________


                   A  BILL  FOR  AN  ACT

RELATING TO INSURANCE.



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

 1      SECTION 1.  Section 431:10C-304, Hawaii Revised Statutes, is
 
 2 amended to read as follows:
 
 3      "§431:10C-304  Obligation to pay personal injury protection
 
 4 benefits.
 
 5      For purposes of this section, the term "personal injury
 
 6 protection insurer" includes personal injury protection self-
 
 7 insurers.  Every personal injury protection insurer shall provide
 
 8 personal injury protection benefits for accidental harm as
 
 9 follows:
 
10      (1)  Except as otherwise provided in section 431:10C-305(d),
 
11           in the case of injury arising out of a motor vehicle
 
12           accident, the insurer shall pay, without regard to
 
13           fault, to the provider of services on behalf of the
 
14           following persons who sustain accidental harm as a
 
15           result of the operation, maintenance, or use of the
 
16           vehicle, an amount equal to the personal injury
 
17           protection benefits as defined in section 431:10C-
 
18           103.5(a) payable for expenses to that person as a
 
19           result of the injury:
 

 
Page 2                                                     2476
                                     H.B. NO.           H.D. 1
                                                        
                                                        

 
 1           (A)  Any person, including the owner, operator,
 
 2                occupant, or user of the insured motor vehicle;
 
 3           (B)  Any pedestrian (including a bicyclist); or
 
 4           (C)  Any user or operator of a moped as defined in
 
 5                section 249-1;
 
 6           provided that this paragraph shall not apply in the
 
 7           case of injury to or death of any operator or passenger
 
 8           of a motorcycle or motor scooter as defined in section
 
 9           286-2 arising out of a motor vehicle accident, unless
 
10           expressly provided for in the motor vehicle policy;
 
11      (2)  Payment of personal injury protection benefits shall be
 
12           made as the benefits accrue, except that in the case of
 
13           death, payment of benefits under section 431:10C-
 
14           302(a)(5) may be made immediately in a lump sum
 
15           payment, at the option of the beneficiary;
 
16      (3)  (A)  Payment of personal injury protection benefits
 
17                shall be made within thirty days after the insurer
 
18                has received reasonable proof of the fact and
 
19                amount of benefits accrued, and demand for payment
 
20                thereof. All providers must produce descriptions
 
21                of the service provided in conformity with
 
22                applicable fee schedule codes;
 

 
 
 
Page 3                                                     2476
                                     H.B. NO.           H.D. 1
                                                        
                                                        

 
 1           (B)  If the insurer elects to deny a claim for benefits
 
 2                in whole or in part, the insurer shall within
 
 3                thirty days, notify the claimant in writing of the
 
 4                denial and the reasons for the denial.  The denial
 
 5                notice shall be prepared and mailed by the insurer
 
 6                in triplicate copies and be in a format approved
 
 7                by the commissioner.  In the case of benefits for
 
 8                services specified in section 431:10C-103.5(a) the
 
 9                insurer shall also mail a copy of the denial to
 
10                the provider; and
 
11           (C)  If the insurer cannot pay or deny the claim for
 
12                benefits because additional information or loss
 
13                documentation is needed, the insurer shall, within
 
14                the thirty days, forward to the claimant an
 
15                itemized list of all the required documents. In
 
16                the case of benefits for services specified in
 
17                section 431:10C-103.5(a) the insurer shall also
 
18                forward the list to the service provider;
 
19      (4)  Amounts of benefits which are unpaid thirty days after
 
20           the insurer has received reasonable proof of the fact
 
21           and the amount of benefits accrued, and demand for
 
22           payment thereof, after the expiration of the thirty
 
23           days, shall bear interest at the rate of one and one-
 
24           half per cent per month;
 

 
Page 4                                                     2476
                                     H.B. NO.           H.D. 1
                                                        
                                                        

 
 1      (5)  No part of personal injury protection benefits paid
 
 2           shall be applied in any manner as attorney's fees in
 
 3           the case of injury or death for which the benefits are
 
 4           paid.  The insurer shall pay, subject to section
 
 5           431:10C-211, in addition to the personal injury
 
 6           protection benefits due, all attorney's fees and costs
 
 7           of settlement or suit necessary to effect the payment
 
 8           of any or all personal injury protection benefits found
 
 9           due under the contract.  Any contract in violation of
 
10           this provision shall be illegal and unenforceable.  It
 
11           shall constitute an unlawful and unethical act for any
 
12           attorney to solicit, enter into, or knowingly accept
 
13           benefits under any contract; [and
 
14      (6)  Any insurer who violates this section shall be subject
 
15           to section 431:10C-117(b) and (c).]
 
16      (6)  Disputes between the provider and the insurer over the
 
17           amount of a charge or the correct fee or procedure code
 
18           to be used under the workers' compensation supplemental
 
19           medical fee schedule shall be governed by section
 
20           431:10C-308.5; and
 
21      (7)  Any insurer who violates this section shall be subject
 
22           to section 431:10C-117(b) and (c)."
 

 
 
 
Page 5                                                     2476
                                     H.B. NO.           H.D. 1
                                                        
                                                        

 
 1      SECTION 2.  Section 431:10C-308.5, Hawaii Revised Statutes,
 
 2 is amended to read as follows:
 
 3      "§431:10C-308.5  Limitation on charges.  (a)  As used in
 
 4 this article, the term ["workers' compensation schedules"]
 
 5 "workers' compensation supplemental medical fee schedule" means
 
 6 the [schedules] schedule adopted and as may be amended by the
 
 7 director of labor and industrial relations for workers'
 
 8 compensation cases under chapter 386, establishing fees and
 
 9 frequency of treatment guidelines[, and contained in sections 12-
 
10 13-30, 12-13-35, 12-13-38, 12-13-39, 12-13-45, 12-13-85 through
 
11 92, and 12-13-94, Hawaii administrative rules].  References in
 
12 the workers' compensation [schedules] supplemental medical fee
 
13 schedule to "the employer", "the director", and "the industrial
 
14 injury", shall be respectively construed as references to "the
 
15 insurer", "the commissioner", and "the injury covered by personal
 
16 injury protection benefits" for purposes of this article.
 
17      (b)  The charges and frequency of treatment for services
 
18 specified in section 431:10C-103.5(a), except for emergency
 
19 services provided within seventy-two hours following a motor
 
20 vehicle accident resulting in injury, shall not exceed the
 
21 charges and frequency of treatment permissible under the workers'
 
22 compensation [schedules.] supplemental medical fee schedule.
 
23 Charges for independent medical examinations, including record
 

 
Page 6                                                     2476
                                     H.B. NO.           H.D. 1
                                                        
                                                        

 
 1 reviews, physical examinations, history taking, and reports, to
 
 2 be conducted by a licensed Hawaii provider unless the insured
 
 3 consents to an out-of-state provider, shall not exceed [the
 
 4 charges permissible under the workers' compensation schedules for
 
 5 consultation for a complex medical problem.] a maximum of      .
 
 6 [The workers' compensation schedules] The maximum charge shall
 
 7 not apply to independent medical examinations conducted by out-
 
 8 of-state providers[; provided that] if the charges for the
 
 9 examination are reasonable.  All records and charges relating to
 
10 an independent medical examination shall be made available to the
 
11 claimant upon request.  The commissioner may adopt administrative
 
12 rules relating to fees or frequency of treatment for injuries
 
13 covered by personal injury protection benefits.  If adopted,
 
14 these administrative rules shall prevail to the extent that they
 
15 are inconsistent with the workers' compensation [schedules.]
 
16 supplemental medical fee schedule.
 
17      (c)  Charges for services for which no fee is set by the
 
18 workers' compensation [schedules] supplemental medical fee
 
19 schedule or other administrative rules adopted by the
 
20 commissioner shall be limited to eighty per cent of the
 
21 provider's usual and customary charges for these services.
 
22      (d)  Services for which no frequency of treatment guidelines
 
23 are set forth in the workers' compensation [schedules]
 

 
Page 7                                                     2476
                                     H.B. NO.           H.D. 1
                                                        
                                                        

 
 1 supplemental medical fee schedule or other administrative rules
 
 2 adopted by the commissioner shall be deemed appropriate and
 
 3 reasonable expenses necessarily incurred if so determined by a
 
 4 provider.
 
 5      (e)  In the event of a dispute between the provider and the
 
 6 insurer over the amount of a charge or the correct fee or
 
 7 procedure code to be used under the workers' compensation
 
 8 supplemental medical fee schedule, the insurer shall:
 
 9      (1)  Pay all undisputed charges within thirty days after the
 
10           insurer has received reasonable proof of the fact and
 
11           amount of benefits accrued and demand for payment
 
12           thereof; and
 
13      (2)  Negotiate in good faith with the provider on the
 
14           disputed charges for a period up to sixty days after
 
15           the insurer has received reasonable proof of the fact
 
16           and amount of benefits accrued and demand for payment
 
17           thereof.
 
18 If the provider and the insurer are unable to resolve the
 
19 dispute, the provider, insurer, or claimant may submit the
 
20 dispute to the commissioner, arbitration, or court of competent
 
21 jurisdiction.  The parties shall include documentation of the
 
22 efforts of the insurer and the provider to reach a negotiated
 
23 resolution of the dispute.
 

 
Page 8                                                     2476
                                     H.B. NO.           H.D. 1
                                                        
                                                        

 
 1      [(e)] (f)  The provider of services described in section
 
 2 431:10C-103.5(a) shall not bill the insured directly for those
 
 3 services but shall bill the insurer for a determination of the
 
 4 amount payable.  The provider shall not bill or otherwise attempt
 
 5 to collect from the insured the difference between the provider's
 
 6 full charge and the amount paid by the insurer.
 
 7      [(f)] (g)  A health care provider shall be compensated by
 
 8 the insurer for preparing reports documenting the need for
 
 9 treatments which exceed the [schedules] workers' compensation
 
10 supplemental medical fee schedule in accordance with the fee
 
11 schedule for special reports.  The health care provider may
 
12 assess the cost of preparing a report to the insurer at no more
 
13 than $20 per page up to a maximum of $75 for each report."
 
14      SECTION 3.  Statutory material to be repealed is bracketed.
 
15 New statutory material is underscored.
 
16      SECTION 4.  This Act shall take effect upon its approval.