SB1472

SECTION 1. The purpose of this Act is to ensure that injured workers have access to prompt, quality medical treatment by requiring the use of clinically tested, evidence based treatment guidelines for their treatment and recovery.

Further, the utilization of clinically tested, evidence based treatment guidelines protects injured employees from the hazardous effects of over-treatment or over-utilization of medical treatment that only further harm the injured employee emotionally, physically, and economically.

The utilization of the Official Disabilities Guidelines ("0DG") Treatment in Workers' Comp, 3rd edition, issued by the Work Loss Data Institute and the treatment guidelines, chapters 1-7, issued by the American College of Occupational and Environmental Medicine, 2^nd Edition is meant to act as a starting point in discussing care most appropriate to the injured employee.

SECTION 2. Section 386-26, Hawaii Revised Statutes, is amended to read as follows:

"§386-26 Guidelines on frequency of treatment and reasonable utilization of health care and services. (a) Frequency and extent of treatment shall be in accordance with the ODG Treatment in Workers' Comp, 3^rd Edition, issued by the Work Loss Data Institute. In addition to the ODG Treatment in Workers' Comp, 3^rd Edition, this section references Chapters 1-7 of the practice guides issued by the American College of Occupational and Environmental Medicine, 2^nd Edition, as an expression of disability management philosophy that should be an integral part of practice within the workers’ compensation system, and as an educational tool for health care providers and other participants practicing in the workers’ compensation system.

(b) The treatment guidelines required by this section are presumed medically necessary and correct, as such, the attending physician is not required to provide a treatment plan to the employer and may begin treatment, so long as the diagnosis is correct and medical treatment conforms to subsection (a). However, the attending physician must inform the employer, on a form prescribed by the department, a diagnosis of the injury.

(c) The presumption in subsection (b) is rebuttable and may be contested by a preponderance of the scientific medical evidence establishing that a variance from the guidelines is reasonably required to cure and relieve the employee from the effects of the injury condition.

(d) For all injuries not covered by the ODG Treatment in Workers' Compensation, 3^rd Edition, or in cases in which the attending physician believes that additional treatments beyond that provided by subsection (a) are necessary or that a treatment guideline different than that specified in subsection (a) is necessary, the attending physician shall mail a treatment plan to the employer at least fourteen calendar days prior to the start of the additional or differing treatments. The treatment plan shall detail:

(1) The attending physician's explanation for deviation from the guidelines established under subsection (a), and that the plan is based upon evidence-based medical treatment guidelines generally recognized by the national medical community and that is scientifically based;

(2) That the proposed treatment plan and guidelines were developed by physicians, with involvement of actively practicing health care providers and are peer-reviewed;

(3) Projected commencement and termination dates of treatment;

(4) A clear statement as to the impression or diagnosis;

(5) Number and frequency of treatments;

(6) Modalities and procedures to be used; and

(7) An estimated total cost of services.

No treatment plan shall be valid that is not based upon evidence-based medical treatment guidelines generally recognized by the national medical community and that is scientifically based. With the exception of emergency medical services, any provider of services who exceeds the treatment guidelines without proper authorization shall be denied compensation for the unauthorized services. Unless agreed by the employee, disallowed fees shall not be charged to the injured employee.

(e) The employer may file an objection to the proposed treatment plan with documentary evidence supporting the denial and a copy of the denied treatment plan or treatment guideline with the director, copying the attending physician and the injured employee. Both the front page of the denial and the envelope in which the denial is filed shall be clearly identified as a "TREATMENT PLAN DENIAL" in capital letters. The employer shall be responsible for payment for treatments provided under a complete treatment plan until the date the objection is filed with the director. Furthermore, the employer's objection letter must explicitly state that if the attending physician or the injured employee does not agree with the denial, they may request a review by the director of the employer's denial within fourteen calendar days after postmark of the employer's denial, and failure to do so shall be construed as acceptance of the employer's denial. In denying medical treatment, the employer must disclose to the attending physician and employee the medically, evidenced-based criteria used as the basis of the objection.

(f) The attending physician or the injured employee may request in writing that the director review the employer's denial of the treatment plan. The request for review shall be filed with the director, copying the employer, within fourteen calendar days after postmark of the employer's denial. A copy of the denied treatment plan shall be submitted with the request for review. Both the front page of the request for review and the envelope in which the request is filed shall be clearly identified as a "REQUEST FOR REVIEW OF TREATMENT PLAN DENIAL" in capital letters. For cases not under the jurisdiction of the director at the time of the request, the injured employee shall be responsible to have the case remanded to the director's jurisdiction. Failure to file a request for review of the employer's denial with the director within fourteen calendar days after postmark of the employer's denial shall be deemed acceptance of the employer's denial.

(g) The director shall issue a decision, after a hearing, either requiring the employer to pay the physician within thirty-one calendar days in accordance with the medical fee schedule if the treatments are determined to be based upon evidence-based medical treatment guidelines generally recognized by the national medical community and that is scientifically based. In determining the treatment for the claimant, the director will give deference to amendments to the ODG Treatment in Workers’ Comp, 3^rd Edition, provided the amendments are based on sound scientifically based criteria. Disallowed fees shall not be charged to the injured employee.

(h) For treatments and services by providers of service other than physicians, treatment shall be in accordance with subsection (a) of this section.

(i) The psychiatric evaluation or psychological testing with the resultant reports shall be limited to four hours unless the physician submits prior documentation indicating the necessity for more time and receives pre-authorization from the employer. Fees shall be calculated on an hourly basis as allowed under Medicare.

(j) Any provider of service who exceeds the treatment guidelines without proper authorization shall not be compensated for the unauthorized services.

(k) No compensation shall be allowed for preparing treatment plans and written justification for treatments which exceed the guidelines.

(l) Failure to comply with the requirements in this section may result in denial of fees.

(m) Treatment, prescribed on an in-patient basis in a licensed acute care hospital where the injured employee's level of care is medically appropriate for an acute setting as determined by community standards, are excluded from the frequency of treatment guidelines specified herein.

[The director shall issue guidelines for the frequency of treatment and for reasonable utilization of medical care and services by health care providers that are considered necessary and appropriate under this chapter. The guidelines shall not be considered as an authoritative prescription for health care, nor shall they preclude any health care provider from drawing upon the health care provider's medical judgment and expertise in determining the most appropriate care.

~~The guidelines shall be adopted pursuant to chapter 91 and shall not interfere with the injured employee's rights to exercise free choice of physicians under section 386-21.~~]

In addition, the director shall adopt updated medical fee schedules referred to in section 386-21, and where deemed appropriate, shall establish separate fee schedules for services of health care providers as defined in section 386-1 to become effective no later than June 30, 1986, in accordance with chapter 91."

SECTION 3. Notwithstanding the requirements under Act 11, Special Session Laws of Hawaii 2005, Chapters 12-15-30 through 12-15-34, Hawaii Administrative Rules, are revoked.

SECTION 4. Statutory material to be repealed is bracketed and stricken. New statutory material is underscored.

SECTION 5. This Act shall take January 1, 2008.

INTRODUCED BY:

_____________________________

BY REQUEST

THE SENATE	S.B. NO.	1472
TWENTY-FOURTH LEGISLATURE, 2007
STATE OF HAWAII