[atlas:bill]

AN ACT Relating to medical issues under the industrial insurance system; amending RCW 51.04.030, 51.32.110, and 51.36.070; and creating a new section.

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

Sec. 1. RCW 51.04.030 and 1998 c 230 s 1 are each amended to read as follows:

(1) The director shall supervise the providing of prompt and efficient care and treatment, including care provided by physician assistants governed by the provisions of chapters 18.57A and 18.71A RCW, acting under a supervising physician, and including chiropractic care, to workers injured during the course of their employment at the least cost consistent with promptness and efficiency, without discrimination or favoritism, and with as great uniformity as the various and diverse surrounding circumstances and locations of industries will permit and to that end shall, from time to time, establish and adopt and supervise the administration of printed forms, rules, regulations, and practices for the furnishing of such care and treatment((~~: PROVIDED, That~~)). This subsection is subject to the following:

(a) The medical coverage decisions of the department do not constitute a "rule" as used in RCW 34.05.010(16), nor are such decisions subject to the rule-making provisions of chapter 34.05 RCW except that criteria for establishing medical coverage decisions shall be adopted by rule after consultation with the workers' compensation advisory committee established in RCW 51.04.110((~~: PROVIDED FURTHER, That~~));

(b) The department may recommend to an injured worker particular health care services and providers where specialized treatment is indicated or where cost effective payment levels or rates are obtained by the department((~~: AND PROVIDED FURTHER, That~~));

(c) The department may enter into contracts for goods and services including, but not limited to, durable medical equipment so long as state-wide access to quality service is maintained for injured workers; and

(d) A department employee is not authorized to practice in any field or specialty in the course of or incident to his or her official duties unless the employee is currently licensed, certified, or registered as a provider in that field or specialty. The department shall adopt rules implementing this subsection (1)(d).

(2) The director shall, in consultation with interested persons, establish and, in his or her discretion, periodically change as may be necessary, and make available a fee schedule of the maximum charges to be made by any physician, surgeon, chiropractor, hospital, druggist, physicians' assistants as defined in chapters 18.57A and 18.71A RCW, acting under a supervising physician or other agency or person rendering services to injured workers. The department shall coordinate with other state purchasers of health care services to establish as much consistency and uniformity in billing and coding practices as possible, taking into account the unique requirements and differences between programs. No service covered under this title, including services provided to injured workers, whether aliens or other injured workers, who are not residing in the United States at the time of receiving the services, shall be charged or paid at a rate or rates exceeding those specified in such fee schedule, and no contract providing for greater fees shall be valid as to the excess. The establishment of such a schedule, exclusive of conversion factors, does not constitute "agency action" as used in RCW 34.05.010(3), nor does such a fee schedule constitute a "rule" as used in RCW 34.05.010(16).

(3) The director or self-insurer, as the case may be, shall make a record of the commencement of every disability and the termination thereof and, when bills are rendered for the care and treatment of injured workers, shall approve and pay those which conform to the adopted rules, regulations, established fee schedules, and practices of the director and may reject any bill or item thereof incurred in violation of the principles laid down in this section or the rules, regulations, or the established fee schedules and rules and regulations adopted under it.

Sec. 2. RCW 51.32.110 and 1997 c 325 s 3 are each amended to read as follows:

(1) Any worker entitled to receive any benefits or claiming such under this title shall, if requested by the department or self-insurer as authorized under this title, submit himself or herself for medical examination, at a time and from time to time, at a place reasonably convenient for the worker and as may be provided by the rules of the department. An injured worker, whether an alien or other injured worker, who is not residing in the United States at the time that a medical examination is requested may be required to submit to an examination at any location in the United States determined by the department or self-insurer.

(2) If the worker refuses to submit to medical examination, or obstructs the same, or, if any injured worker shall persist in unsanitary or injurious practices which tend to imperil or retard his or her recovery, or shall refuse to submit to such medical or surgical treatment as is reasonably essential to his or her recovery or refuse or obstruct evaluation or examination for the purpose of vocational rehabilitation or does not cooperate in reasonable efforts at such rehabilitation, the department or the self-insurer upon approval by the department, with notice to the worker may suspend any further action on any claim of such worker so long as such refusal, obstruction, noncooperation, or practice continues and reduce, suspend, or deny any compensation for such period: PROVIDED, That the department or the self-insurer shall not suspend any further action on any claim of a worker or reduce, suspend, or deny any compensation if a worker has good cause for refusing to submit to or to obstruct any examination, evaluation, treatment or practice requested by the department or required under this section.

(3) If the worker necessarily incurs traveling expenses in attending the examination pursuant to the request of the department, such traveling expenses shall be repaid to him or her out of the accident fund upon proper voucher and audit or shall be repaid by the self-insurer, as the case may be.

(4)(a) If the medical examination required by this section causes the worker to be absent from his or her work without pay:

(i) In the case of a worker insured by the department, the worker shall be paid compensation out of the accident fund in an amount equal to his or her usual wages for the time lost from work while attending the medical examination; or

(ii) In the case of a worker of a self-insurer, the self-insurer shall pay the worker an amount equal to his or her usual wages for the time lost from work while attending the medical examination.

(b) This subsection (4) shall apply prospectively to all claims regardless of the date of injury.

Sec. 3. RCW 51.36.070 and 1977 ex.s. c 350 s 60 are each amended to read as follows:

(1) Subject to the requirements of this title, whenever the director or the self-insurer deems it necessary ((~~in order to resolve any medical issue, a~~)) to order a medical examination of a worker, the worker shall submit to examination by a ((~~physician or physicians~~)) provider or providers selected by the director, with the rendition of a report to the person ordering the examination. The director, in his or her discretion, may charge the cost of such examination or examinations to the self-insurer or to the medical aid fund as the case may be. The cost of said examination shall include payment to the worker of reasonable expenses connected therewith.

(2) Examinations by the worker's treating provider or providers may be ordered whenever necessary to resolve a medical issue. Examinations by independent examiners may be ordered only in the following circumstances:

(a) To resolve a disagreement among the treating providers concerning the best course of treatment or the need for continuing treatment;

(b) To determine whether the worker's condition is fixed and stable after completion of a course of treatment, if the treating provider agrees that the course of treatment is complete. If the treating provider does not agree that the course of treatment is complete, an examination by an independent examiner may be ordered under this subsection only if the examiner is chosen by agreement between the worker and the department or self-insurer;

(c) To provide consultation to the worker's treating provider when the care of the worker has exceeded practice parameters established by the department. The consultation is limited to reviewing diagnoses, determining the reason that care has exceeded practice parameters, and/or providing suggestions for alternate diagnoses and treatment procedures.

(3) The course of treatment or care, including emergency services, for an accepted condition may not be interrupted or delayed pending the examination report of an independent examiner unless the director or designee finds that the treatment or care is not medically necessary. This subsection does not apply to procedures, determined by department rule, that can be delayed without harm to the injured worker until a consultation opinion is obtained.

(4) If the department or self-insurer relies on the report of an independent examiner to deny, limit, or terminate benefits to a worker, the examiner must be currently licensed, certified, or registered to practice in the same field or specialty as the claimant's treating provider or providers.

(5) Any provider licensed to practice in medicine and surgery under chapter 18.71 RCW, osteopathic medicine and surgery under chapter 18.57 RCW, podiatric medicine and surgery under chapter 18.22 RCW, dentistry under chapter 18.30 RCW, chiropractic under chapter 18.25 RCW, and psychology under chapter 18.83 RCW may be an independent examiner, within the appropriate scope of practice for the examination to be performed and subject to department rules regarding approval as an independent examiner.

(6) For purposes of this section, "independent examiner" means a provider or panel of providers, none of whom are a treating provider for the worker being examined.

(7) This section does not apply to special examinations for determining permanent disabilities.

NEW SECTION. Sec. 4. This act applies to all medical examinations, other than special examinations for determining permanent disabilities, ordered by the department of labor and industries or a self-insured employer under Title 51 RCW on or after the effective date of this act.