Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 2 - Medical Guidelines
Chapter 27 - Utilization Review Procedures
Section I-2719 - Instructions for On-Site Audit of Hospital Charges by Workers' Compensation Carrier

a. The claims to be audited should be identified as quickly as possible after the carrier/self-insured employer receives the claim.

b. The carrier/self-insured employer or its audit agency should give 10 calendar days advance notice to the hospital of its desire to perform an audit. The carrier/self-insured employer or its audit agency should make an appointment to do the audit at the time that is mutually agreed to by both parties. At the time the appointment is made, the hospital shall be informed of:

c. Qualified individuals familiar with hospital billing practices, medical terminology and medical record charting must be used to perform the billing audit.

d. Auditors must be properly authorized and identified as representatives of the carrier/self-insured employer or its audit agency.

e.

f. Auditors should itemize specific unsupported charges and unbilled charges found on hospital bills. The final audit findings will offset unbilled charges against unsupported charges in a reconciliation process to be completed by the carrier/self-insured employer after receiving the audit report which should include a listing of all unbilled charges and unsupported billings.

g. Auditors should conduct exit interviews with a hospital's audit coordinator and/or other appropriate hospital personnel prior to leaving to permit the review of the preliminary audit results before issuing a final report. If the exit interview is waived by the hospital, this fact should be indicated in writing.

h. A written report of the final audit results should be sent to all interested parties in a timely fashion.

a. Hospitals must schedule an appointment to audit a bill promptly upon the receipt of a request for such an appointment, at a time mutually agreed upon by the hospital and the carrier/self-insured employer or its audit agency no later than 10 days from receipt of request.

b. Hospitals should respond promptly to a request for an itemized bill from the carrier/self-insured employer or its agent.

c. Hospitals should respond promptly to requests for additional information on the period of hospitalization, including information from the medical record and from the billing office.

d. Hospitals should designate one individual to be responsible for coordinating all hospital audit activities, and act as a liaison between provider personnel and the carrier/self-insured employer. This would include informing appropriate hospital departments of pending audits and audit results, answering carrier/self-insured employer questions, insuring that a late charge bill is sent to the patient or carrier/self-insured employer, issuing a refund to the appropriate party, etc. After notice of a proposed audit has been received by the hospital, this individual should coordinate between the medical records department and the billing office to insure that medical records, financial records, and any other documentation needed to substantiate charges are provided and available for the audit.

e. The hospital liaison shall acquaint the carrier/self-insured employer representative or audit agent with its record system and charging practices.

f. All substances administered to the patient in any form, as well as all treatments or medical services, must be specifically and accurately documented.

g. The hospital's representative will be available to the carrier/self-insured employer to conduct an exit interview. Discrepancies will be reviewed, resolved, and agreed upon by both parties. This will be done by written confirmation of the unbilled and/or undocumented charges identified during the audit and signed by both parties. In the event that same day resolution is not possible, the hospital, in a timely manner, should resolve differences in any unsupported or unbilled amounts resulting from the audit.

h. The hospital should issue refunds promptly if overcharges and/or undocumented charges exceeding the balance of the carrier/self-insured employer liability are discovered during the audit.

i. Hospitals may not bill for undocumented charges discovered during the bill audit process. However, hospitals may bill for documented and previously unbilled charges discovered during the bill audit process, for charges in excess of the audit fee charged by the hospital.