Louisiana Administrative Code
Title 37 - INSURANCE Part
Part XIII - Regulations
Chapter 25 - Regulation 49-Billing Audit Guidelines
Section XIII-2505 - Definitions
Current through Register Vol. 50, No. 9, September 20, 2024
A. For purposes of this regulation:
Ambulatory Surgical Center- ambulatory surgical center as defined in R.S. 40:2133(A).
Billing Audit- a process to determine whether data in a provider's medical record documents or supports services listed on a provider's bill. Billing audit does not mean a review of medical necessity of services provided, cost or pricing policy of a facility, and adjustments for "usual and customary".
Health Record which Shall Mean Medical Record- any compilation of charts, records, reports, documents, and other memoranda prepared by a health care provider, wherever located, to record or indicate the past or present condition, sickness, or disease, and treatment rendered, physical or mental, of a patient.
Historic Error Rate- the average error found during all audits conducted by external qualified billing auditors during the preceding calendar year. It shall be calculated by totaling the net adjustments made to all accounts audited by external qualified billing auditors during that year and dividing that total by the total amount claimed by the audited party to be due on those accounts immediately preceding the audit. This calculation results is an average error rate for all externally audited cases expressed as a percentage.
Hospital- hospital as defined in R.S. 40:2102(A).
Patient- a natural person who receives or should have received health care from a health care provider, under a contract, expressed or implied.
Qualified Billing Auditor- a person employed by a corporation or firm that is recognized as competent to perform or coordinate billing audits and that has explicit policies and procedures protecting the confidentiality of all the patient information in their possession and disposal of this information.
Unbilled Charges- the volume of services indicated on a bill is less than the volume identified in a provider's health record documentation; also known as undercharges.
Unsupported or Undocumented Charges- the volume of services indicated on a bill exceeds the total volume identified in a provider's health record documentation; also known as overcharges.
AUTHORITY NOTE: Promulgated in accordance with Act 664 of the 1993 Regular Legislative Session and R.S. 22:12.
