La. Admin. Code tit. 40 § I-5101

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-5101 - Statement of Policy

A. It is the intent of this reimbursement schedule to limit to the mean of the usual and customary charge all fees for medical services, supplies, and other non-medical services delivered to workers' compensation claimants, as authorized by law.

B. The law provides that an employer or compensation insurer owes to an injured worker 100 percent of the medical fees incurred in the treatment of work-related injuries or occupational diseases [hereinafter referred to as "illness(es)"].

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 LDOL-WC-1008 (Disputed Claim for Compensation) with the Office of Workers' Compensation within 30 days of the date of receipt 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 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 does not know the workers' compensation status, or the workers' compensation insurer has denied coverage, the provider will not 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, CPT-4, CDT-1, NDAS 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 are to be used in conjunction with Chapter 27 rules on utilization review procedures.

8. Sales taxes and other state mandated taxes are required to be reimbursed in addition to other procedure, supplies or medical services.

La. Admin. Code tit. 40, § I-5101

Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:54 (January 1993), repromulgated LR 19:212 (February 1993), amended LR 20:1299 (November 1994), amended by the Workforce Commission, Office of Workers' Compensation, LR 40:375 (February 2014), Amended by the Workforce Commission, Office of Workers' Compensation Administration, LR 42288 (2/1/2016).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.