17-1741

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HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1741
UTILIZATION CONTROL
§17-1741-1 	Purpose
§17-1741-2 	Definitions
§17-1741-3 	Surveillance and utilization review
§17-1741-4 	Provider over-utilization or abuse
§17-1741-5 	Referrals to the medicaid investigations
division
§17-1741-6 	Recipient over-utilization or abuse
§17-1741-7 	Restriction
Historical Notes: 	Chapter 17-1741 is based
substantially upon chapter 17-1350. [Eff 6/29/92;
R 08/01/94 	]
§17-1741-1 	Purpose. 	This chapter shall implement
the State Plan requirements for a statewide
surveillance and utilization control program and a
fraud detection and investigation program.
[Eff 08/01/94 	] 	(Auth: 	HRS §346-14; 42 C.F.R.
§§430.10, 431.10) 	(Imp: 	42 C.F.R. §§455.1, 456.3,
456.4)
§17-1741-2 	REPEALED. 	[R 09/30/13]
§17-1741-3 	Surveillance and utilization review.
To safeguard against unnecessary or inappropriate use
of services under the medical assistance program,
excess payments and to assess the quality of those
services, the department shall:

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(1) 	Conduct post payment reviews and audits of a
statistically significant sampling of
provider claims;
(2) 	Compare provider and recipient utilization of
services to establish statistical models of
average provider and recipient utilization
patterns;
(3) 	Select for review those providers and
recipients with exceptional utilization
patterns; and
(4) 	Take necessary remedial measures and
corrective action to ensure the effectiveness
of the program. 	[Eff 08/01/94 	] 	(Auth:
HRS §346-14; 42 C.F.R. §§430.10, 431.10,
456.1) 	(Imp: 	42 C.F.R. §§456.1,
456.3-456.6, 456.22, 456.23)
§17-1741-4 	Provider over-utilization or abuse.
(a) 	If the findings of the review indicate possible
abuse, the department shall conduct a full
investigation.
(b) 	In the event that the department is unable to
determine whether the actions of a provider constitute
improper medical practice, the department requests an
opinion of the Hawaii Medical Association peer review
committee.
(c) 	When incorrect practices result in
overpayment, the department shall:
(1) 	Notify the provider of any aberrances;
(2) 	Request the provider to take corrective
action; and
(3) 	Establish a monitoring program of the
provider's medicaid practice to ensure
corrective measures have been introduced.
(d) 	Any overpayment made by the medical
assistance program shall require repayment by the
provider. 	Payment on the provider's pending claims may
be withheld in part or in whole to be applied to the
overpayments previously made to the provider by the
medical assistance program. 	[Eff 08/01/94 	]
(Auth: 	HRS §346-14; 42 C.F.R. §§431.10, 456.12) 	(Imp:
42 C.F.R. §§455.13, 455.14, 455.15, 455.16)
§17-1741-5 	Referrals to the medicaid
investigations division. 	Referrals shall include all
cases of suspected provider fraud and complaints

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alleging abuse or neglect of patients in health care
facilities including misappropriation of patient's
private funds in such facilities. 	[Eff 08/01/94 	]
(Auth: 	HRS §346-14; 42 C.F.R. §431.10) 	(Imp: 	42
C.F.R. §§455.13, 455.15)
§17-1741-6 	Recipient over-utilization or abuse.
(a) 	Freedom of choice in selecting health care
providers shall not include the expedient utilization
or over-utilization of the community’s health care
providers and supplies.
(b) 	When a recipient over-utilizes medical
services, the department shall request the recipient’s
voluntary cooperation in curbing abusive utilization
practices and shall monitor the recipient’s case for no
less than six months.
(c) 	When a recipient has been shown to be over-
utilizing controlled drugs with multiple prescriptions
filled at more than one pharmacy and written by
multiple prescribers, the department shall require the
recipient to choose one primary care physician and one
pharmacy to be the only approved providers of usual
care. 	The department also reserves the right to ask
the recipient to choose another provider if the
physician is known to the department to be over-
prescribing medications or medical services. 	Refer to
section 17-1741-7 for specific details regarding
restrictions.
(d) 	When a recipient has been determined to be
using excessive medical services provided by multiple
physicians, the department may assist the recipient in
receiving appropriate coordinated care. 	As a result,
the department shall ask the recipient to choose one
primary care provider to coordinate all usual services
for the recipient and make referrals to other
providers, as needed. 	Refer to section
17-1741-7 for specific details regarding restrictions.
[Eff 08/01/94; am 07/06/99 	] 	(Auth: 	HRS §346-14;
42 C.F.R. §431.10) 	(Imp: 	42 C.F.R. §§456.3, 456.23)
§17-1741-7 	Restriction. 	(a) 	If over-utilization
or abuse continues, the recipient shall be
administratively restricted for no less than
twenty-four months to a primary care physician who is:
(1) 	Of the client's choice;

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(2) 	Willing to provide and coordinate services to
the client; and
(3) 	Certified by the department to participate in
the medical assistance program.
(b) 	A recipient who over-utilizes services which
are provided by psychotherapists, pharmacies and
dentists shall also be restricted to those providers if
necessary, to further curb recipient abuse.
(c) 	The individual who is restricted shall be
afforded advance notice and appeals process.
(d) 	Emergency medical services shall not require
the referral, assistance, or approval of the designated
primary care physician.
(e) 	The restricted recipient shall receive a
medical authorization card bearing the designated
primary care physician until:
(1) 	Responsibility for care is transferred to
another physician;
(2) 	The recipient requests a change in the
primary care physicians and the department
and the affected physician concurs; or
(3) 	Control is no longer considered necessary by
the designated primary care physician and the
department's medical consultant concurs.
(f) 	If a recipient fails to select a primary care
physician within thirty days following receipt of
notice of medical service restrictions, the department
shall select a physician who is in good standing with
the medical program.
(g) 	When a physician willing to participate as
the primary care physician cannot be found, the
department's medical consultant shall provide prior
approval for all health service required by the
restricted recipient with the exception of emergency
care.(h) 	The designated physician shall:
(1) 	Provide and coordinate all medical services
to the client, except for emergency services;
(2) 	Make referrals for other needed health
services; and
(3) 	Inform the department when the designated
physician is no longer able to provide
medical services to the recipient.
(i) 	A recipient shall continue to be restricted
to a designated provider(s) until:
(1) 	There is documented evidence of that
individual's compliance for at least one full
year; and

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(2) 	The primary care physician and the
department's medical consultant concur.
(j) 	When the decision is made to continue
restriction, the recipient shall be afforded advance
notice and the appeals process.
(k) 	The recipient whose restriction has been
terminated shall be monitored for no less than
twenty-four months and placed back on restriction if
there is evidence of recurrent over-utilization or
abuse of medicaid services during that period.
[Eff 08/01/94 	] 	(Auth: 	HRS §346-14; 42 C.F.R.
§431.10) 	(Imp: 	42 C.F.R. §§456.3, 456.23)