PART II. COMPENSATION

 

A.  Medicaland Rehabilitation Benefits

 

Cross References

 

  Limitation on charges, see §431:10C-308.5.

 

§386‑21  Medical care, services, andsupplies.  (a)  Immediately after a work injury sustained by an employeeand so long as reasonably needed the employer shall furnish to the employee allmedical care, services, and supplies as the nature of the injury requires.  Theliability for the medical care, services, and supplies shall be subject to thedeductible under section 386‑100.

(b)  Whenever medical care is needed, theinjured employee may select any physician or surgeon who is practicing on theisland where the injury was incurred to render medical care.  If the servicesof a specialist are indicated, the employee may select any physician or surgeonpracticing in the State.  The director may authorize the selection of aspecialist practicing outside the State where no comparable medical attendancewithin the State is available.  Upon procuring the services of a physician or surgeon,the injured employee shall give proper notice of the employee's selection tothe employer within a reasonable time after the beginning of the treatment.  Iffor any reason during the period when medical care is needed, the employeewishes to change to another physician or surgeon, the employee may do so inaccordance with rules prescribed by the director.  If the employee is unable toselect a physician or surgeon and the emergency nature of the injury requiresimmediate medical attendance, or if the employee does not desire to select aphysician or surgeon and so advises the employer, the employer shall select thephysician or surgeon.  The selection, however, shall not deprive the employeeof the employee's right of subsequently selecting a physician or surgeon forcontinuance of needed medical care.

(c)  The liability of the employer for medicalcare, services, and supplies shall be limited to the charges computed as setforth in this section.  The director shall make determinations of the charges andadopt fee schedules based upon those determinations.  Effective January 1,1997, and for each succeeding calendar year thereafter, the charges shall notexceed one hundred ten per cent of fees prescribed in the Medicare ResourceBased Relative Value Scale applicable to Hawaii as prepared by the UnitedStates Department of Health and Human Services, except as provided in thissubsection.  The rates or fees provided for in this section shall be adequateto ensure at all times the standard of services and care intended by thischapter to injured employees.

If the director determines that an allowanceunder the medicare program is not reasonable or if a medical treatment,accommodation, product, or service existing as of June 29, 1995, is not coveredunder the medicare program, the director, at any time, may establish anadditional fee schedule or schedules not exceeding the prevalent charge forfees for services actually received by providers of health care services, tocover charges for that treatment, accommodation, product, or service.  If noprevalent charge for a fee for service has been established for a given serviceor procedure, the director shall adopt a reasonable rate which shall be thesame for all providers of health care services to be paid for that service orprocedure.

The director shall update the schedulesrequired by this section every three years or annually, as required.  Theupdates shall be based upon:

(1)  Future charges or additions prescribed in theMedicare Resource Based Relative Value Scale applicable to Hawaii as preparedby the United States Department of Health and Human Services; or

(2)  A statistically valid survey by the director ofprevalent charges for fees for services actually received by providers ofhealth care services or based upon the information provided to the director bythe appropriate state agency having access to prevalent charges for medical feeinformation.

When a dispute exists between an insurer orself-insured employer and a medical services provider regarding the amount of afee for medical services, the director may resolve the dispute in a summarymanner as the director may prescribe; provided that a provider shall not chargemore than the provider's private patient charge for the service rendered.

When a dispute exists between an employee andthe employer or the employer's insurer regarding the proposed treatment plan orwhether medical services should be continued, the employee shall continue toreceive essential medical services prescribed by the treating physiciannecessary to prevent deterioration of the employee's condition or furtherinjury until the director issues a decision on whether the employee's medicaltreatment should be continued.  The director shall make a decision withinthirty days of the filing of a dispute.  If the director determines thatmedical services pursuant to the treatment plan should be or should have beendiscontinued, the director shall designate the date after which medicalservices for that treatment plan are denied.  The employer or the employer'sinsurer may recover from the employee's personal health care provider qualifiedpursuant to section 386-27, or from any other appropriate occupational ornon-occupational insurer, all the sums paid for medical services rendered afterthe date designated by the director.  Under no circumstances shall the employeebe charged for the disallowed services, unless the services were obtained inviolation of section 386-98.  The attending physician, employee, employer, orinsurance carrier may request in writing that the director review the denial ofthe treatment plan or the continuation of medical services.

(d)  The director, with input from stakeholdersin the workers' compensation system, including but not limited to insurers,health care providers, employers, and employees, shall establish standardizedforms for health care providers to use when reporting on and billing forinjuries compensable under this chapter.  The forms may be in triplicate, or inany other configuration so as to minimize, to the extent practicable, the needfor a health care provider to fill out multiple forms describing the sameworkers' compensation case to the department, the injured employee's employer,and the employer's insurer.

(e)  If it appears to the director that theinjured employee has wilfully refused to accept the services of a competentphysician or surgeon selected as provided in this section, or has wilfullyobstructed the physician or surgeon, or medical, surgical, or hospital servicesor supplies, the director may consider such refusal or obstruction on the partof the injured employee to be a waiver in whole or in part of the right tomedical care, services, and supplies, and may suspend the weekly benefitpayments, if any, to which the employee is entitled so long as the refusal orobstruction continues.

(f)  Any funds as are periodically necessary tothe department to implement the foregoing provisions may be charged to and paidfrom the special compensation fund provided by section 386-151.

(g)  In cases where the compensability of theclaim is not contested by the employer, the medical services provider shallnotify or bill the employer, insurer, or the special compensation fund forservices rendered relating to the compensable injury within two years of thedate services were rendered.  Failure to bill the employer, insurer, or thespecial compensation fund within the two-year period shall result in theforfeiture of the medical services provider's right to payment.  The medical [services]provider shall not directly charge the injured employee for treatments relatingto the compensable injury. [L 1963, c 116, pt of §1; Supp, §97-20; am L 1967, c16, §1; HRS §386-21; am L 1973, c 78, §1; am L 1979, c 132, §1; am L 1985, c296, §15; gen ch 1985; am L 1987, c 120, §1; am L 1995, c 234, §7; am L 1996, c260, §2; am L 1998, c 191, §1; am L 2006, c 191, §1; am L Sp 2009, c 26, §1]

 

Case Notes

 

  Offsets for workers' compensation benefits in pension planconstituted forfeitures under ERISA.  504 F. Supp. 958.

  Workers' compensation benefits clearly intended to indemnifyworkers for job related injury or disease, not to provide income lost onretirement.  504 F. Supp. 958.

  Voluntary, involuntary medical attendance.  32 H. 503.

  A decision that finally adjudicates the matter of medical andtemporary disability benefits under §§386-31(b), 386-32(b), and this section isan appealable final order under §91-14(a), even though the matter of permanentdisability benefits under §§386-31(a) and 386-32(a) has been left for laterdetermination.  89 H. 436, 974 P.2d 1026.

  There is no statutory authority granted to board to apportionthe medical treatment coverage afforded under this section between apreexisting dental condition and the accident-induced temporomandibular jointdisorder; where substantial evidence in record indicated that the medicaltreatment proposed was necessitated by the nature of the injury, the employerwas required to provide compensation for "all" medical treatment required. 93 H. 116 (App.), 997 P.2d 42.

  Cited:  24 H. 731, 733.