Louisiana Administrative Code › Title 40 - LABOR AND EMPLOYMENT › Part I - Workers' Compensation Administration › Subpart 2 - Medical Guidelines › Chapter 51 - Medical Reimbursement Schedule › Section I-5101 - Statement of Policy

Current through Register Vol. 50, No. 6, June 20, 2024
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.