La. Admin. Code tit. 40 § I-2701

Current through Register Vol. 50, No. 9, September 20, 2024

Section I-2701 - Statement of Policy

A. It is the intent of this rule to establish procedures and policies appropriate to the fulfillment of the powers, duties, and functions of the director of the Office of Workers' Compensation as set forth in R.S. 23:1291 (Act 938 of the 1988 Regular Session). R.S. 23:1291 empowers the director of the Office of Workers' Compensation:

1. "to resolve disputes over the necessity, advisability, and cost of proposed or already performed hospital care or services, medical or surgical treatment, or any nonmedical treatment recognized by the laws of this state as legal."; and

2. "to audit the specific medical records of the patient under treatment by any health care provider who has furnished services or treatment to a person covered by this Chapter, or the records of any person or entity rendering care, services, or treatment or furnishing drugs or supplies for the purpose of determining whether an inappropriate reimbursement has been made."

B. The law provides that after the promulgation of the medical treatment schedule, medical care, services, and treatment due, pursuant to R.S. 23:1203 et seq., by the employer to the employee incurred in the treatment of work-related injuries or occupational diseases [hereinafter referred to as "illness(es)"] shall mean care, services, and treatment in accordance with the medical treatment schedule.

1. It is therefore the policy of the Office of Workers' Compensation that medical bills for services should be sent to the carrier/self-insured employer for payment. Fees for covered services in excess of the amounts allowable under the terms of this schedule are not recoverable from the employer, insurer, or employee.

2. It is also deemed to be in the best interest of all of the parties in the system that fees for services reasonably performed and billed in accordance with the reimbursement schedule should be promptly paid. Not paying or formally contesting such bills by filing LWC-WC-1008 (disputed claim for compensation), with the Office of Workers' Compensation within 60 days of the date of receipt of the bill may subject the carrier/self-insured employer to penalties and attorneys fees. Additionally, frivolous contesting of the bill may subject the carrier/self-insured employer to penalties and attorneys fees.

3. If claimant is receiving treatment for both compensable and noncompensable medical conditions, only those services provided in treatment of compensable conditions should be listed on invoices submitted to the carrier/self-insured employer unless the noncompensable condition (e.g., hypertension, diabetes) has a direct bearing on the treatment of the compensable condition. In addition, payments from private payers for noncompensable conditions should not be listed on invoices submitted to the carrier/self-insured employer. If a provider reasonably doesn't know the workers' compensation status, or the workers' compensation insurer has denied coverage, the provider won't be penalized for not complying with this rule. Upon notification or knowledge of workers' compensation eligibility, the provider will comply with these regulations prospectively.

4. Statements of charges shall be made in accordance with standard coding methodology as established by these rules, ICD-10-CM, ICD-10-PCS, HCPCS, and CPT-4 coding manuals. Unbundling or fragmenting charges, duplicating or over-itemizing coding, or engaging in any other practice for the purpose of inflating bills or reimbursement is strictly prohibited. Services must be coded and charged in the manner guaranteeing the lowest charge applicable. Knowingly and willfully misrepresenting services provided to workers' compensation claimants is strictly prohibited.

5. Providers should take reasonable steps to ensure that only those services provided are billed to the carrier/self-insured employer. Violation of this provision may subject provider/practitioner to mandatory audit of all charges.

6. Bills for a particular charge item may not be included in subsequent billings without clear indication that they have been previously billed.

7. These rules must be used in addition to all the reimbursement rules.

La. Admin. Code tit. 40, § I-2701

Promulgated by the Department of Employment and Training, Office of Workers' Compensation, LR 17:263 (March 1991), repromulgated LR 17:653 (July 1991), amended by the Louisiana Workforce Commission, Office of Workers' Compensation, LR 38:1030 (April 2012), amended by the Louisiana Workforce Commission, Office of Workers' Compensation, LR 38:1030 (April 2012), Amended by the Workforce Commission, Office of Workers' Compensation Administration, LR 42284 (2/1/2016).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1291.