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

Current through Register Vol. 50, No. 6, June 20, 2024
A. The carrier
				  is authorized to conduct an on-site audit of hospital services related to a
				  compensable injury or illness. This is accomplished by a line-by-line
				  examination of billed charges, comparing the doctor's orders with supporting
				  medical documentation in the patient's chart and the corresponding departmental
				  records.
B. The following audit
				  guidelines will be followed by hospitals and carrier/self-insured employer.
				  Disputes between the carrier/self-insured employer and hospitals will be
				  referred to the Office of Workers Compensation for final resolution.
1. Carrier/Self-Insured Employer
				  Responsibilities
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:
i. the name(s) of patient(s) whose records
				  are to be audited;
ii. the
				  admission and discharge dates for each case;
iii. the medical record numbers and billing
				  numbers of the claims to be audited, as assigned by the hospital, if those
				  appear on the claim;
iv. the
				  name(s) of the auditor(s) who will conduct the audit, if available, and the
				  name of the audit firm if the carrier/self-insured employer is contracting for
				  auditing services;
v. the portion
				  of the bill to be audited (i.e., drugs, respiratory therapy, etc.) if the
				  entire bill is not to be audited.
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.
i.Recognizing that no single standard exists
				  for the payment of hospital bills prior to audit, or for audit fees charged by
				  hospitals, the Office of Workers' Compensation recommends the following
				  guidelines.
(a). The carrier/self-insured
				  employer should pay at least 80 percent of billed charges prior to the audit.
				  If an audit fee is charged by the provider, it should not exceed $50 per
				  patient record plus copy charges as provided below.
(b). The carrier/self-insured employer will
				  reimburse the hospital for copies of medical records at the following rates:
				  Fees will not exceed $15 per record for 1-20 pages, and $0.30 per page for
				  records in excess of 20 pages. Microfilm copies will not exceed $0.50 per
				  page.
ii. Should the
				  carrier/self-insured employer and hospital not be able to agree to this
				  standard or some other standard, either party may submit the dispute to the
				  Office of Workers' Compensation Administration in the same manner and subject
				  to the same procedures as established for dispute resolution of claims for
				  workers' compensation benefits.
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.