Current through Register Vol. 50, No. 9, September 20, 2024
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.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
23:1291.
