Things for your doctor to know

Medical providers (whether in Hawaii or on the mainland) are all required to comply with the Hawaii Workers Compensation Medical Fee Schedule (“HWCMFS”) both in submission of treatment plans as well as billings (which are submitted to the insurance carrier, and not this firm).

Some key elements to the Guidelines are:

1. There is no such thing as “preapproved” medical care. Although you as the medical provider may sometimes contact an adjuster who will “preapprove” care, the Guidelines do not mandate any such preapproval. (The only type of “preapproval” that is required pertains to diagnostic imaging studies beyond the intial one hundred and twenty (120) days of treatment. HAR § 12-15-54) The Guidelines provide that medical care rendered pursuant to a valid treatment plan must be paid at least up until the date of any written – not verbal -- denial by the carrier. HAR § 12-15-32(c) Thereafter, a hearing must be requested by either you, the claimant or the claimant’s representative within fourteen (14) calendar days from the date of the denial, otherwise the denial is deemed valid. At the hearing a hearings officer will determine whether the denial was appropriate or not.
2. Treatment plans must be periodically submitted to the employer/carrier by you along with Hawaii Workers Compensation Form WC-2, (which is submitted monthly and includes inclusive date of disability), HAR § 12-15-80) which is available on our website. HAR §12-15-32 All the six (6) elements of HAR § 12-15-32(b) must be contained in the treatment plan for the plan to be considered valid. There is no uniform form for this. The treatment plan must not have a commencement date of less than seven (7) days notice from the submission to the carrier of the treatment plan. The treatment plan shall be for one hundred and twenty (120) days and provide for no more than fifteen (15) treatments. (These same limitations apply to concurrent care; HAR § 12-15-40)
3. There is only one attending physician (you). Any other concurrent care must be pursuant to a valid treatment plan. HAR § 12-15-40.
4. Requests for consultations with other medical providers to assist in the care and treatment of the injured worker must set forth the name, business address, discipline and specialty of the consulting physician and the reason for the consultation at least seven (7) calendar days prior to the referral. The carrier’s failure to object to the referral within seven (7) calendar days constitutes approval of the referral. HAR § 12-15-42
5. Requests for elective surgery must be made and submitted to the carrier no less than seven (7) days prior to the date of the proposed surgery and must contain the information set forth in HAR § 12-15-51(a). Unless objected to within seven (7) days of the request, the surgery is deemed approved. HAR § 12-15-51(b)
6. All correspondence pertaining to this Hawaii Workers Compensation claim must include the injured employee’s full name, the Disability Compensation Division (“DCD”) case number, the date of accident, the name of the employer, and if applicable, the name of the carrier. HAR § 12-10-71

Keep in mind that just because a carrier objects or denies medical treatment does not mean ipso facto the objection or denial is valid. It is up to the Department of Labor, upon a hearing, to make that determination. In other words, don’t cave in just because the carrier sends a denial or objection letter. It’s their job to limit payout of expenses, whether or not the basis is legitimate.

It’s this firm’s job to ensure the claimant receives all benefits properly payable, including valid medical care.

To view the HAR Section 12-15, which pertains to medical care and treatment, click here. To view Exhibit "A" to the Guidlines, which contains the biling codes and unit values for medical treatment, click here.