December 15, 2011, Introduced by Reps. Yonker, Liss and O'Brien and referred to the Committee on Insurance.
A bill to amend 1969 PA 317, entitled
"Worker's disability compensation act of 1969,"
by amending section 315 (MCL 418.315), as amended by 2009 PA 226.
THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
Sec. 315. (1) The employer shall furnish, or cause to be
furnished, to an employee who receives a personal injury arising
out of and in the course of employment, reasonable medical,
surgical, and hospital services and medicines, or other attendance
or treatment recognized by the laws of this state as legal, when
they are needed. However, an employer is not required to reimburse
or cause to be reimbursed charges for an optometric service unless
that service was included in the definition of practice of
optometry under section 17401 of the public health code, 1978 PA
368, MCL 333.17401, as of May 20, 1992 or for a chiropractic
service unless that service was included in the definition of
practice of chiropractic under section 16401 of the public health
code, 1978 PA 368, MCL 333.16401, as of January 1, 2009. An
employer is not required to reimburse or cause to be reimbursed
charges for services performed by a profession that was not
licensed or registered by the laws of this state on or before
January 1, 1998, but that becomes licensed, registered, or
otherwise recognized by the laws of this state after January 1,
1998. An employer is not required to reimburse or cause to be
reimbursed charges for physical therapy service unless that service
was provided by a licensed physical therapist or physical therapist
assistant under the supervision of a licensed physical therapist
pursuant to a prescription issued by an individual holding a
license issued under part 166, 170, 175, or 180 of the public
health code, 1978 PA 368, MCL 333.16601 to 333.16648, 333.17001 to
333.17084, 333.17501 to 333.17556, and 333.18001 to 333.18058, or
the equivalent license issued by another state. Attendant or
nursing care shall not be ordered in excess of 56 hours per week if
the care is to be provided by the employee's spouse, brother,
sister, child, parent, or any combination of these persons. After
10 days from the inception of medical care as provided in this
section, the employee may treat with a physician of his or her own
choice by giving to the employer the name of the physician and his
or her intention to treat with the physician. The employer or the
employer's carrier may file a petition objecting to the named
physician selected by the employee and setting forth reasons for
the objection. If the employer or carrier can show cause why the
employee should not continue treatment with the named physician of
the employee's choice, after notice to all parties and a prompt
hearing by a worker's compensation magistrate, the worker's
compensation magistrate may order that the employee discontinue
treatment with the named physician or pay for the treatment
received from the physician from the date the order is mailed. The
employer shall also supply to the injured employee dental service,
crutches, artificial limbs, eyes, teeth, eyeglasses, hearing
apparatus, and other appliances necessary to cure, so far as
reasonably possible, and relieve from the effects of the injury. If
the employer fails, neglects, or refuses so to do, the employee
shall be reimbursed for the reasonable expense paid by the
employee, or payment may be made in behalf of the employee to
persons to whom the unpaid expenses may be owing, by order of the
worker's compensation magistrate. The worker's compensation
magistrate may prorate attorney fees at the contingent fee rate
paid by the employee.
(2) Except as otherwise provided in subsection (1), all fees
and other charges for any treatment or attendance, service,
devices, apparatus, or medicine under subsection (1), are subject
to rules promulgated by the workers' compensation agency pursuant
to the administrative procedures act of 1969, 1969 PA 306, MCL
24.201 to 24.328. The rules promulgated shall establish schedules
of maximum charges for the treatment or attendance, service,
devices, apparatus, or medicine, which schedule shall be annually
revised. A health facility or health care provider shall be paid
either its usual and customary charge for the treatment or
attendance, service, devices, apparatus, or medicine, or the
maximum charge established under the rules, whichever is less.
(3) The director of the workers' compensation agency shall
provide for an advisory committee to aid and assist in establishing
the schedules of maximum charges under subsection (2) for charges
or fees that are payable under this section. The advisory committee
shall be appointed by and serve at the pleasure of the director.
(4) If a carrier determines that a health facility or health
care provider has made any excessive charges or required
unjustified treatment, hospitalization, or visits, the health
facility or health care provider shall not receive payment under
this chapter from the carrier for the excessive fees or unjustified
treatment, hospitalization, or visits, and is liable to return to
the carrier the fees or charges already collected. The workers'
compensation agency may review the records and medical bills of a
health facility or health care provider determined by a carrier to
not be in compliance with the schedule of charges or to be
requiring unjustified treatment, hospitalization, or office visits.
(5) As used in this section, "utilization review" means the
initial evaluation by a carrier of the appropriateness in terms of
both the level and the quality of health care and health services
provided an injured employee, based on medically accepted
standards. A utilization review shall be accomplished by a carrier
pursuant to a system established by the workers' compensation
agency that identifies the utilization of health care and health
services above the usual range of utilization for the health care
and health services based on medically accepted standards and
provides for acquiring necessary records, medical bills, and other
information concerning the health care or health services.
(6) By accepting payment under this chapter, a health facility
or health care provider shall be considered to have consented to
submitting necessary records and other information concerning
health care or health services provided for utilization review
pursuant to this section. The health facilities and health care
providers shall be considered to have agreed to comply with any
decision of the workers' compensation agency pursuant to subsection
(7). A health facility or health care provider that submits false
or misleading records or other information to a carrier or the
workers' compensation agency is guilty of a misdemeanor punishable
by a fine of not more than $1,000.00 or by imprisonment for not
more than 1 year, or both.
(7) If it is determined by a carrier that a health facility or
health care provider improperly overutilized or otherwise rendered
or ordered inappropriate health care or health services, or that
the cost of the health care or health services was inappropriate,
the health facility or health care provider may appeal to the
workers' compensation agency regarding that determination pursuant
to procedures provided for under the system of utilization review.
(8) The criteria or standards established for the utilization
review shall be established by rules promulgated by the workers'
compensation agency. A carrier that complies with the criteria or
standards as determined by the workers' compensation agency shall
be certified by the department.
(9) If a health facility or health care provider provides
health care or a health service that is not usually associated
with, is longer in duration in time than, is more frequent than, or
extends over a greater number of days than that health care or
service usually does with the diagnosis or condition for which the
patient is being treated, the health facility or health care
provider may be required by the carrier to explain the necessity or
indication for the reasons why in writing.
Enacting section 1. This amendatory act does not take effect
unless House Bill No. 4603 of the 96th Legislature is enacted into
law.