HOUSE BILL NO. 5182

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 2014 PA 264.

the people of the state of michigan enact:

Sec. 315. (1) The Except as otherwise provided under subsection (2), an employer shall furnish, or cause to be furnished, all of the following, as applicable, to an employee who receives a personal injury arising out of and in the course of employment: , reasonable

(a) Reasonable and timely 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

(b) Dental service.

(c) Crutches.

(d) Artificial limbs, eyes, or teeth.

(e) Eyeglasses, hearing apparatuses, or other appliances that may cure, so far as reasonably possible, or ameliorate the effects of the injury.

(2) An employer is not required to reimburse or cause to be reimbursed charges for an any of the following:

(a) 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

(b) 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 not licensed or registered by the laws of this state that was performed by a profession 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 a

(c) A 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 from a health care professional who holds a license issued under part 166, 170, 175, or 180 of the public health code, 1978 PA 368, MCL 333.16601 to 333.16648, 333.16659, 333.17001 to 333.17084, 333.17097, 333.17501 to 333.17556, and 333.18001 to 333.18058, or the equivalent license issued by another state.

(3) Attendant or nursing care shall must not be ordered in excess of 56 84 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 28

(4) Ten days from after the inception of medical care as provided in this section, employee provides notice of injury under section 381, the employee may treat with a physician or health care provider of his or her the employee's own choice by giving if the employee gives to the employer or employer's carrier the name of the physician or health care provider and his or her notice of the employee's intention to treat with the physician or health care provider. If the employer or carrier does not furnish, or cause to be furnished, reasonable and timely care 10 days or fewer after the notice of injury was provided, the employee may treat with a physician or health care provider of the employee's own choice and the employer or carrier shall pay for the treatment provided by the physician or health care provider.

(5) It is presumed that treatment provided or recommended by a physician or health care provider of the employee's own choice is reasonable.

(6) An employer or the employer's carrier shall provide an open claim letter to a physician or health care provider of the employee's own choice not later than 7 days after the employer receives notice as described in subsection (4). If an employer or carrier does not provide the physician or health care provider an open claim letter, the employer or carrier must pay the employee $100.00 per day until the employer or carrier provides the open claim letter. Payments made to an employee under this subsection must not exceed $25,000.00.

(7) The employer or the employer's carrier may file a petition objecting that objects to the named physician selected by or health care provider of the employee employee's own choice and setting forth provides reasons for the objection. If the employer or carrier can show cause why the employee should not continue treatment with the named physician or health care provider of the employee's own 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 health care provider or pay for the treatment received from the physician or health care provider 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.Not later than 10 days after the employee provides notice of injury under section 381, the employer or carrier shall provide notice to the employee, on a form and in a manner prescribed by the director, of the employee's right to choose a physician or health care provider under this section and of the employer's obligation to furnish, or cause to be furnished, any treatment, attendance, service, device, apparatus, appliance, or medicine under this section.

(8) An injured employee or the injured employee's physician or health care provider may make a request in writing, including electronically, to the employer, the employer's carrier, or a third party administrator for preauthorization for payment of benefits for proposed treatment, attendance, service, device, apparatus, appliance, or medicine under this section. The request must explain why the proposed treatment, attendance, service, device, apparatus, appliance, or medicine is reasonable. If the employer, employer's carrier, or third party administrator does not authorize a request described under this subsection 10 days or fewer after receiving the request, the injured employee may file an application for mediation or hearing with the agency to obtain the medical care described under this subsection. A worker's compensation magistrate may give a case described under this subsection precedence over other cases assigned to the magistrate.

(9) Subject to subsection (2), a worker's compensation magistrate shall order an employer, an employer's carrier, or a third party administrator to pay for any reasonable unpaid expenses, reasonable expenses paid for by or on behalf of the employee, or any reasonable proposed treatment, attendance, service, device, apparatus, appliance, or medication if the employer, employer's carrier, or third party administrator does any of the following:

(a) Does not or refuses to furnish, cause to be furnished, or pay for any reasonable treatment, attendance, service, device, apparatus, appliance, or medicine.

(b) Does not provide authorization as described in subsection (8) 10 business days or fewer after receiving the preauthorization request.

(10) A worker's compensation magistrate shall order an employer, an employer's carrier, or a third party administrator to pay the reasonable costs of litigation and attorney fees of the attorney who secured an order to pay under subsection (9) at the rate of 30% of the amount of the unpaid charges, reimbursed expenses, or costs of proposed treatment, attendance, service, device, apparatus, appliance, or medication ordered.

(11) (2) Except as otherwise provided in subsection (1), this section, all fees and other charges for any treatment or attendance, service, devices, apparatus, or medicine under subsection (1), this section are subject to rules promulgated by the workers' compensation agency pursuant to under the administrative procedures act of 1969, 1969 PA 306, MCL 24.201 to 24.328. The rules promulgated shall must establish schedules of maximum charges for the treatment, or attendance, service, devices, apparatus, appliance, or medicine, which schedule shall and the schedules of maximum charges must be annually revised. A health facility or health care provider shall must be paid either its usual and customary charge for the treatment, or attendance, service, devices, apparatus, appliance, or medicine, or the maximum charge established under the rules, whichever is less.

(12) (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) (11) for charges or fees that are payable under this section. The director shall appoint the advisory committee. shall be appointed by and The advisory committee shall serve at the pleasure of the director.

(13) (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 must 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.

(14) (6) By accepting payment under this chapter, a health facility or health care provider is considered to have agreed to submit necessary records and other information concerning health care or health services provided for utilization review pursuant to under this section. The health facilities and health care providers are considered to have agreed to comply with any decision of the workers' compensation agency pursuant to under subsection (7). (15). 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.

(15) (7) If a carrier determines that a health facility or health care provider improperly overutilized overutilizes or otherwise rendered renders or ordered orders inappropriate health care or health services, or that the cost of the health care or health services was is inappropriate, the health facility or health care provider may appeal the determination to the workers' compensation agency pursuant to in accordance with procedures provided for under the system of utilization review.

(16) (8) The workers' compensation agency shall establish criteria or standards for utilization review by rule. A carrier that complies with the criteria or standards as determined by the workers' compensation agency shall must be certified by the department.

(17) (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 requires for the diagnosis or condition for which the patient is being treated, the carrier may require the health facility or health care provider to explain the necessity or indication for that health care or service in writing.

(18) If a physician or health care provider receives a request for billings from any party for any alleged, work-related medical treatment, attendance, service, device, apparatus, appliance, or medication, the physician or health care provider must provide the billings on a form designated by the agency based on the schedules of maximum charges described under subsection (11) to the requester not later than 60 days after receipt of the request. If the magistrate determines that the medical bill charges are related to a work injury or disease, but the care provided by the physician or health care provider is not reasonable, the physician or health care provider may not recover payment for the portion of care that is determined to be unreasonable. If the physician or health care provider does not provide the billings as requested on the proper form 180 days or fewer after receiving a request, the physician or health care provider cannot recover payment from the employer, employer's carrier, third party administrator or the employee in any claim before the agency or in any other legal or equitable action.

(19) As used in this section:

(a) "Open claim letter" means a letter from the employer, the employer's carrier, or a third party administrator that advises a physician or health care provider that the employer, employer's carrier, or third party administrator is responsible for paying for an employee's reasonable care under this act, for an injury or disease arising out of the employee's course of employment that caused, contributed to, aggravated, accelerated, or worsened the employee's symptoms or pathology related to a physical or mental condition. An open claim letter must include a contact person's name, mailing address, email address, and a reliable and accessible telephone number for the responsible party so that claims can be properly submitted or authorizations for treatment can be obtained.

(b) "Third party administrator" means that term as used in section 659.

(c) "Utilization review" means the initial evaluation by a carrier of the appropriateness of both the level and the quality of health care and health services provided an injured employee, based on medically accepted standards, accomplished by a carrier in accordance with 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.