REPORT TITLE:
Insurance



DESCRIPTION:
Creates a uniform reference to the "workers' compensation
supplemental medical fee schedule."  (SD1)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                        2476
HOUSE OF REPRESENTATIVES                H.B. NO.           H.D. 1
TWENTIETH LEGISLATURE, 2000                                S.D. 1
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.  For purposes of this section, the term "personal
 
 5 injury protection insurer" includes personal injury protection
 
 6 self-insurers.  Every personal injury protection insurer shall
 
 7 provide personal injury protection benefits for accidental harm
 
 8 as follows:
 
 9      (1)  Except as otherwise provided in section 431:10C-305(d),
 
10           in the case of injury arising out of a motor vehicle
 
11           accident, the insurer shall pay, without regard to
 
12           fault, to the provider of services on behalf of the
 
13           following persons who sustain accidental harm as a
 
14           result of the operation, maintenance, or use of the
 
15           vehicle, an amount equal to the personal injury
 
16           protection benefits as defined in section 431:10C-
 
17           103.5(a) payable for expenses to that person as a
 
18           result of the injury:
 
19           (A)  Any person, including the owner, operator,
 

 
Page 2                                                     2476
                                     H.B. NO.           H.D. 1
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 1                occupant, or user of the insured motor vehicle;
 
 2           (B)  Any pedestrian (including a bicyclist); or
 
 3           (C)  Any user or operator of a moped as defined in
 
 4                section 249-1;
 
 5           provided that this paragraph shall not apply in the
 
 6           case of injury to or death of any operator or passenger
 
 7           of a motorcycle or motor scooter as defined in section
 
 8           286-2 arising out of a motor vehicle accident, unless
 
 9           expressly provided for in the motor vehicle policy;
 
10      (2)  Payment of personal injury protection benefits shall be
 
11           made as the benefits accrue, except that in the case of
 
12           death, payment of benefits under section 431:10C-
 
13           302(a)(5) may be made immediately in a lump sum
 
14           payment, at the option of the beneficiary;
 
15      (3)  (A)  Payment of personal injury protection benefits
 
16                shall be made within thirty days after the insurer
 
17                has received reasonable proof of the fact and
 
18                amount of benefits accrued, and demand for payment
 
19                thereof. All providers must produce descriptions
 
20                of the service provided in conformity with
 
21                applicable fee schedule codes;
 
22           (B)  If the insurer elects to deny a claim for benefits
 
23                in whole or in part, the insurer shall, within
 

 
Page 3                                                     2476
                                     H.B. NO.           H.D. 1
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 1                thirty days, notify the claimant in writing of the
 
 2                denial and the reasons for the denial.  The denial
 
 3                notice shall be prepared and mailed by the insurer
 
 4                in triplicate copies and be in a format approved
 
 5                by the commissioner.  In the case of benefits for
 
 6                services specified in section 431:10C-103.5(a) the
 
 7                insurer shall also mail a copy of the denial to
 
 8                the provider; and
 
 9           (C)  If the insurer cannot pay or deny the claim for
 
10                benefits because additional information or loss
 
11                documentation is needed, the insurer shall, within
 
12                the thirty days, forward to the claimant an
 
13                itemized list of all the required documents. In
 
14                the case of benefits for services specified in
 
15                section 431:10C-103.5(a) the insurer shall also
 
16                forward the list to the service provider;
 
17      (4)  Amounts of benefits which are unpaid thirty days after
 
18           the insurer has received reasonable proof of the fact
 
19           and the amount of benefits accrued, and demand for
 
20           payment thereof, after the expiration of the thirty
 
21           days, shall bear interest at the rate of one and one-
 
22           half per cent per month;
 
23      (5)  No part of personal injury protection benefits paid
 

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

 
 1           shall be applied in any manner as attorney's fees in
 
 2           the case of injury or death for which the benefits are
 
 3           paid.  The insurer shall pay, subject to section
 
 4           431:10C-211, in addition to the personal injury
 
 5           protection benefits due, all attorney's fees and costs
 
 6           of settlement or suit necessary to effect the payment
 
 7           of any or all personal injury protection benefits found
 
 8           due under the contract.  Any contract in violation of
 
 9           this provision shall be illegal and unenforceable.  It
 
10           shall constitute an unlawful and unethical act for any
 
11           attorney to solicit, enter into, or knowingly accept
 
12           benefits under any contract; [and
 
13      (6)  Any insurer who violates this section shall be subject
 
14           to section 431:10C-117(b) and (c).]
 
15      (6)  Disputes between the provider and the insurer over the
 
16           amount of a charge or the correct fee or procedure code
 
17           to be used under the workers' compensation supplemental
 
18           medical fee schedule shall be governed by section
 
19           431:10C-308.5; and
 
20      (7)  Any insurer who violates this section shall be subject
 
21           to section 431:10C-117(b) and (c)."
 
22      SECTION 2.  Section 431:10C-308.5, Hawaii Revised Statutes,
 
23 is amended to read as follows:
 

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

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

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

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

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

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

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

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