REPORT TITLE:
Medical Fee Schedule

DESCRIPTION:
Clarifies mechanism for providers to request changes in workers'
compensation medical fee schedule.  (SD1)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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THE SENATE                              S.B. NO.           S.D. 1
TWENTIETH LEGISLATURE, 1999                                
STATE OF HAWAII                                            
                                                             
________________________________________________________________
________________________________________________________________


                   A  BILL  FOR  AN  ACT

RELATING TO MEDICAL FEE SCHEDULES.
 


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

 1      SECTION 1.  Section 386-21, Hawaii Revised Statutes, is
 
 2 amended to read as follows:
 
 3      "§386-21  Medical care, services, and supplies.(a)
 
 4 Immediately after a work injury sustained by an employee and so
 
 5 long as reasonably needed the employer shall furnish to the
 
 6 employee all medical care, services, and supplies as the nature
 
 7 of the injury requires.  The liability for the medical care,
 
 8 services, and supplies shall be subject to the deductible under
 
 9 section 386-100.
 
10      (b)  Whenever medical care is needed, the injured employee
 
11 may select any physician or surgeon who is practicing on the
 
12 island where the injury was incurred to render such care.  If the
 
13 services of a specialist are indicated, the employee may select
 
14 any such physician or surgeon practicing in the State.  The
 
15 director may authorize the selection of a specialist practicing
 
16 outside the State where no comparable medical attendance within
 
17 the State is available.  Upon procuring the services of such
 
18 physician or surgeon, the injured employee shall give proper
 
19 notice of the employee's selection to the employer within a
 

 
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 1 reasonable time after the beginning of the treatment.  If for any
 
 2 reason during the period when medical care is needed, the
 
 3 employee wishes to change to another physician or surgeon, the
 
 4 employee may do so in accordance with rules prescribed by the
 
 5 director.  If the employee is unable to select a physician or
 
 6 surgeon and the emergency nature of the injury requires immediate
 
 7 medical attendance, or if the employee does not desire to select
 
 8 a physician or surgeon and so advises the employer, the employer
 
 9 shall select the physician or surgeon.  Such selection, however,
 
10 shall not deprive the employee of the employee's right of
 
11 subsequently selecting a physician or surgeon for continuance of
 
12 needed medical care.
 
13      (c)  The liability of the employer for medical care,
 
14 services, and supplies shall be limited to the charges computed
 
15 as set forth in this section.  The director shall make
 
16 determinations of the charges and adopt fee schedules based upon
 
17 those determinations.  Effective January 1, 1997, and for each
 
18 succeeding calendar year thereafter, the charges shall not exceed
 
19 one hundred ten per cent of fees prescribed in the Medicare
 
20 Resource Based Relative Value Scale system applicable to Hawaii
 
21 as prepared by the United States Department of Health and Human
 
22 Services, except as provided in this subsection.  The rates or
 
23 fees provided for in this section shall be adequate to ensure at
 

 
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 1 all times the standard of services and care intended by this
 
 2 chapter to injured employees.
 
 3      If the director determines that an allowance under the
 
 4 Medicare program is not reasonable, or if a medical treatment,
 
 5 accommodation, product, or service existing as of June 29, 1995,
 
 6 is not covered under the Medicare program, the director may, at
 
 7 any time, establish an additional fee schedule or schedules not
 
 8 exceeding the prevalent charge for fees for services actually
 
 9 received by providers of health care services to cover charges
 
10 for that treatment, accommodation, product, or service.  If no
 
11 prevalent charge for a fee for service has been established for a
 
12 given service or procedure, the director shall adopt a reasonable
 
13 rate that shall be the same for all providers of health care
 
14 services to be paid for that service or procedure.
 
15      The director shall update the schedules required by this
 
16 section every three years or annually, as required[.]; provided
 
17 that the director may update specified fees upon the request of a
 
18 medical service provider in accordance with subsection (g).  The
 
19 updates shall be based upon:
 
20      (1)  Future charges or additions prescribed in the Medicare
 
21           Resource Based Relative Value Scale system applicable
 
22           to Hawaii as prepared by the United States Department
 
23           of Health and Human Services; or
 

 
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 1      (2)  A statistically valid survey by the director of
 
 2           prevalent charges for fees for services actually
 
 3           received by providers of health care services or based
 
 4           upon the information provided to the director by the
 
 5           appropriate state agency having access to prevalent
 
 6           charges for medical fee information.
 
 7      When a dispute exists between an insurer or self-insured
 
 8 employer and a medical service provider regarding the amount of a
 
 9 fee for medical services, the director may resolve the dispute in
 
10 a summary manner as the director may prescribe; provided that a
 
11 provider shall not charge more than the provider's private
 
12 patient charge for the service rendered.
 
13      (d)  If it appears to the director that the injured employee
 
14 has wilfully refused to accept the services of a competent
 
15 physician or surgeon selected as provided in this section, or has
 
16 wilfully obstructed the physician or surgeon, or medical,
 
17 surgical, or hospital services or supplies, the director may
 
18 consider such refusal or obstruction on the part of the injured
 
19 employee to be a waiver in whole or in part of the right to
 
20 medical care, services, and supplies, and may suspend the weekly
 
21 benefit payments, if any, to which the employee is entitled so
 
22 long as such refusal or obstruction continues.
 
23      (e)  Such funds as are periodically necessary to the
 

 
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 1 department to implement the foregoing provisions may be charged
 
 2 to and paid from the special compensation fund provided by
 
 3 section 386-151.
 
 4      (f)  In cases where the compensability of the claim is not
 
 5 contested by the employer, the medical services provider shall
 
 6 notify or bill the employer, insurer, or the special compensation
 
 7 fund for services rendered relating to the compensable injury
 
 8 within two years of the date services were rendered.  Failure to
 
 9 bill the employer, insurer, or the special compensation fund
 
10 within the two year period shall result in the forfeiture of the
 
11 medical service provider's right to payment.  The medical service
 
12 provider shall not directly charge the injured employee for
 
13 treatments relating to the compensable injury.
 
14      (g)  Any medical services provider or a professional
 
15 organization or association of medical services providers may
 
16 request in writing to the director a change in a fee in any fee
 
17 schedule established under subsection (c).  The request shall be
 
18 accompanied by evidence substantiating the need for the change in
 
19 the specified fee.  The director shall review the request and if
 
20 the requested change complies with the requirements of subsection
 
21 (c), then the director shall revise the specified fee as
 
22 requested."
 
23      SECTION 2.  Statutory material to be repealed is bracketed.
 

 
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 1 New statutory material is underscored.
 
 2      SECTION 3.  This Act shall take effect upon approval.