How to Get Medical Care Approved

Unfortunately, Louisiana workers compensation insurance companies love to deny medical treatment to injured employees.

As horrible as it is, the best strategy for these insurance companies’ financial bottom lines is to delay and deny medical treatment.

In fact, to discourage the injured employee from receiving full medical treatment, these workers compensation insurance companies have devised a complicated process called Utilization Review.

Utilization Review is Louisiana law, but make no mistake; it was devised by the workers compensation insurance companies and then sold to the Louisiana legislature by the insurance companies’ lobbyists.

Some workers compensation insurance companies perform longer investigations for more expensive treatments, like hospitalizations and surgeries, and others just outright deny certain claims no matter what.

So these workers compensation insurance companies have made the process for approving medical so complicated and difficult, in the hopes that:

• Employees will give up on getting the full treatment they deserve;
• Medical providers will seek approval for less than what the employee deserves; and
• Attorneys, employees, and medical providers will not challenge the insurance companies on their denials.

The only way to ensure that an injured employee is receiving the full medical care he or she deserves is for the employee to work with an attorney and a doctor who understand the workers compensation Utilization Review process, and are willing to fight to get the full medical care that the injured employee deserves.

What Is the Utilization Review Process in Louisiana Workers Compensation?

“Utilization Review” in Louisiana workers compensation is a set of rules in Louisiana workers compensation that require the use of appropriate procedures in order to:

1. Establish standards of care for medical professionals;
2. Determine the necessity and advisability of proposed medical treatment (such as doctor’s visits, hospital care, or surgical treatment); and
3. Determine the necessity and advisability of proposed non-medical treatment recognized under Louisiana law.

So Utilization Review in Louisiana workers compensation is basically an effort to control the cost of medical care and yet assure that employees receive “all necessary medical treatment” to which they are entitled.

So when is medical care determined to be “necessary” in Louisiana workers compensation?

Well, “medical necessity” is specifically defined in the Utilization Review rules as:

1. Consistent with the diagnosis and treatment of a condition or complaint;
2. Consistent with the standards of good medical practice;
3. Not solely for the convenience of the patient, family, hospital or physician; and
4. Furnished in the most appropriate and least intensive type of medical care setting required by the patient’s condition.

So the workers compensation insurance company must provide an injured worker with “all necessary drugs, supplies, hospital care and services, medical and surgical treatment, and any non-medical treatment recognized by the laws of this state as legal.”

The workers compensation insurance company must also repair or replace any prosthetic devices which might have been damaged by the accident, such as eyeglasses and hearing aids.

And the workers compensation insurance company is liable for “actual expenses reasonably and necessarily incurred” by the employee for travel to obtain the required medical services or prosthetic devices at the mileage rate established for state employees.

The Approval Process for Medical Treatment

Again, the workers compensation insurance company must pay for all the medical bills related to the employee’s work-related accident.

However, the workers compensation insurance company’s advance approval is required for treatment beyond $750 unless the medical treatment is provided under emergency circumstances.

These “Utilization Review” rules also provide appropriate procedures to be followed when an injured employee seeks approval from the workers compensation insurance company to begin or continue treatment beyond the limit of $750.

The Utilization Review process contains deadlines and procedures for authorization and appeal of requested medical treatment under the Medical Guideline Schedule.

Basically, Louisiana law requires the workers compensation insurance company to follow a Utilization Review procedure in deciding whether to approve medical care.

The typical basic Utilization Review process, in a nutshell, is as follows:

• The medical provider requests authorization for treatment from the workers compensation insurance company, and the insurance company must notify the medical provider within five business days of receipt of the request of the action taken on it.
• If the request is denied, “any aggrieved party” must file, within 15 calendar days, an appeal with the OWCA medical director, who then renders a decision “as soon as is practicable” but in no event more than 30 days from the filing of the appeal.
• After the issuance of the OWCA medical director’s decision, “any party who disagrees” with the decision may then appeal by filing a ‘Disputed Claim for Compensation’ Form 1008 within 15 days after the mailing of the decision of the medical director.
• This filing of Form 1008 begins the ordinary legal process for other workers compensation claims.
• A workers compensation judge then considers the decision by the medical director and may reverse it “when it is shown, by clear and convincing evidence” that the decision of the medical director “was not in accordance with the provisions of this Section.”

Unfortunately, this process unfolds very frequently because the workers compensation insurance companies regularly and routinely ignore or deny requests for medical treatment and testing.

Louisiana’s Medical Treatment Guidelines

As noted above, the Utilization Review process contains deadlines and procedures for authorization and appeal of requested medical treatment under the Medical Treatment Guidelines.

So What Are Louisiana’s Medical Treatment Guidelines?

Louisiana’s Medical Treatment Guidelines are the rules which the OWC Medical Director uses to decide whether or not proposed medical treatment should be authorized.

The purpose these Medical Treatment Guidelines is to assist with the decision making process regarding proposed medical treatment for the injured worker.

A copy of the Medical Treatment Guidelines is available here.

Who Must Comply with Louisiana’s Medical Treatment Guidelines?

All medical providers and workers compensation insurance carriers are expected to comply with Louisiana’s Medical Treatment Guidelines.

Requests for a medical treatment that do not comply with the Medical Treatment Guidelines will not be approved unless the injured employee can prove by a preponderance of scientific medical evidence that a variance is appropriate under the specific circumstances of the employee’s case.
Also, even if a medical provider complies with the Medical Treatment Guidelines, this medical provider still must obtain approval from the workers compensation insurance company for any medical services exceeding the statutory limit of $750.

Louisiana’s Medical Reimbursement Fee Schedule

Once again, the workers compensation insurance company must pay for all necessary medical expenses, including drugs, supplies, hospital care, a medical and surgical treatment that related to the injured employee’s accident.

The amounts that can be billed by the medical providers for these medical services and treatments – or rates for reimbursement – are outlined in Louisiana’s Medical Reimbursement Fee Schedule.

That is, the amounts that a medical provider can charge for its services are limited by the Medical Reimbursement Fee Schedule, and payments for all medical fees are limited to the Medical Reimbursement Fee Schedule.

The Medical Reimbursement Fee Schedule limits charges to “the mean of the usual and customary charges” for the covered services and annual adjustments are permissible.

And any fees in excess of the Medical Reimbursement Fee Schedule are not recoverable against the employee, the employer, or the workers compensation insurance company.

But when the workers compensation insurance company denies the compensability of the employee’s claim from the beginning, it must pay the actual medical expenses incurred – not the amounts listed in the Medical Reimbursement Fee Schedule.

Any disputes between a health care provider and the workers compensation insurance company are to be resolved in the same manner and under the same procedures as a typical disputed claim for benefits, including the use of the medical Utilization Review procedures.

A copy of the Medical Reimbursement Fee Schedule is available here.

Which Medical Treatments Need to Undergo the Utilization Review Process in Louisiana Workers Compensation?

As stated above, the Utilization Review rules require the use of appropriate procedures to determine the necessity and advisability of proposed hospital care or services, medical or surgical treatment, or any non-medical treatment recognized by Louisiana law as legal.

And all medical providers and insurance carriers are expected to comply with the Utilization Review rules.

In fact, the workers compensation insurance company is subject to an award of attorney’s fees related to the dispute, as well as any additional medical expenses caused by a refusal to agree to treatment if that refusal is found by a workers compensation Judge to have been arbitrary.

But not all medical treatment is subject to the Utilization Review rules.

Treatment Costing Less than $750

An injured employee does not have to get pre-approval from the workers compensation insurance company if the cost of the medical treatment is less than $750.

And a health care provider may not incur more than $750 in “non-emergency diagnostic testing or treatment” without the approval of the workers compensation insurance company.

If the health care provider does “ring up” more than $750, the obligation to pay the provider’s fee is not “enforceable” against the workers compensation insurance company.

Emergency Treatment

Emergency treatment is not subject to the Utilization Review rules.

So an injured employee does not need to get pre-approval from the workers compensation insurance company for any treatment that is due to an emergency.

And the emergency medical services can cost over $750 without the need to get pre-approval.

However, the injured employee must be able to prove that the treatment was, in fact, of an emergency nature.

For example, though trips to the hospital emergency room are typically for emergency treatment, an injured employee cannot just expect to show up at an emergency room and get non-emergency treatment costing over $750 and expect the workers compensation insurance company to reimburse later.

In fact, all non-emergency hospital admissions must be pre-certified with an appropriate length of stay being assigned, and a continued stay review must also be performed on each approved admission.

Office Visits with The Doctor

Though an individual office visit with a doctor rarely costs more than $750, office visits with the employee’s doctor usually are subject to the Utilization Review rules (and thus need pre-approval), because the office visits will be considered as a group of visits over a period of time.

Specifically, once an injured employee has reached the initial $750 limit on non-emergency care, the health care provider must request authorization from the workers compensation insurance company to continue treating the employee.

Once this initial authorization request is approved, the health care provider will not be required to submit another authorization request for additional office visits during the 12 months following the accident date, or 12 visits, whichever comes first. But these 12 visits include the visits billed before when the employee reached the $750 limit.

After this 12-month period, the provider must submit a new authorization request for additional office visits. If approved, the workers compensation insurance company must authorize at least four additional doctor’s visits.

However, this 12-month provision does not apply to any other services – such as X-rays, MRIs, or other procedures or treatments – provided by this medical provider. Instead, this medical provider will need to submit additional authorization requests for such services other than the doctor’s office visits.

When the Insurer Denies Compensability

If the workers compensation insurance company denies that the employee’s injury is compensable – meaning that the insurer denies the claim and instead says that no money or benefits are to be paid – then no prior approval is necessary for any medical treatment.

This is because when the workers compensation insurance company denies compensability – even for just a specific body part – no issue is presented for review by the Medical Director since it does not involve a dispute as to whether the medical treatment is in accordance with the Medical Treatment Guidelines.

In other words, a dispute as to whether an injury even occurred should not involve the Medical Director deciding which treatment is appropriate, even though it is not uncommon for the workers compensation insurance company to accept certain injuries as compensable and dispute others. 

Also, even when the workers compensation insurance company denies compensability – such as by saying the injury was not caused by the work accident – the employee still must show that the medical expenses were necessary.

But, on the other hand, the workers compensation insurance company is subject to an award of attorney’s fees related to the dispute as well as any additional medical expenses caused by a refusal to agree to treatment, if its refusal is found by a court to have been arbitrary and without proper reason.

Second Medical Opinions versus The Utilization Review Process in Louisiana Workers Compensation

Under Louisiana law, an injured employee has the right to select one treating physician in any field or specialty.

But at the same time, an injured employee is required to submit to an examination by a physician provided and paid for by the employer or the workers compensation insurance company, as soon after the accident as demanded.

This examination by the insurance company’s doctor is called a Second Medical Opinion (SMO).

Instead of treatment, the purpose of the insurance company’s Second Medical Opinion (SMO) doctor is to dispute the opinion and treatment plan of the injured employee’s treating physician.

In other words, the purpose of the insurance company’s Second Medical Opinion (SMO) doctor is to provide a basis on which the insurance company can deny workers compensation benefits due to the employee. 

Utilization Review or Second Medical Opinion (SMO)?

So Second Medical Opinions (SMOs) can be extremely helpful to the workers compensation insurance company.

However, disputes over whether medical treatment is necessary are decided through the Utilization Review process (beginning with the OWC Medical Services Division), and not by a doctor performing a Second Medical Opinion (SMO).

The purpose of a Second Medical Opinion is instead to address questions of medical causation, the employee’s physical condition, and the extent of the employee’s work capabilities.

In other words, if the workers compensation insurance company and the injured employee dispute whether a particular type of treatment recommended by the treating physician is medically necessary, the Utilization Review process is the appropriate forum to resolve this dispute.

But if the workers compensation insurance company claims that the employee’s complaints are not related to the work accident, or if it disputes the employee’s inability to work, then the workers compensation insurance company should have the employee examined by a Second Medical Opinion doctor. 

Of course, an SMO doctor could give an opinion on what he or she thinks is reasonable and necessary medical care, in order for the workers compensation Judge to consider.

But Louisiana law requires that a decision first be made by the Medical Director in the Utilization Review process before the OWC Judge determines whether the Medical Director’s decision was correct (and potentially at that point considers the opinion of the SMO doctor).

How Exactly Does the Utilization Review Process Work in Louisiana Workers Compensation?

According to the Louisiana Office of Workers Compensation, the Utilization Review process for paying workers compensation medical claims is verbatim as follows:

• An employee has the right to select one doctor of his or her choice in each specialty field for treatment of the job-related injury. The employer or its workers compensation insurer is required to pay all approved necessary expenses for medical treatment and all reasonably and necessarily incurred travel to obtain treatment. Medical benefits payable under the Louisiana Workers Compensation Act shall be paid within 30 days after the employer or its workers compensation insurer receives written notice thereof, or within 60 days if the provider of medical services is not utilizing the electronic billing rules and regulations provided for in R.S. 23:1203.2. An itemized list of out of pocket medical expenses and receipts paid by the employee should be sent to the employer or its workers compensation insurer for reimbursement.
• Any non-emergency medical services over $750 and any non-emergency hospitalization must be pre-approved by the employer or its workers compensation insurer. The health care provider seeking authorization to exceed the $750 statutory limit for medical services must submit a request for such authorization to the employer or its workers compensation insurer on an Form LWC-WC 1010 (Request of Authorization/Carrier or Self Insured Employer Response). The Form LWC-WC 1010 and all supporting medical documentation are to be faxed to the employer or its workers compensation insurer and/or the designated utilization review representative. Within five business days of receipt of the Form LWC-WC 1010 and the supporting documentation from the health care provider, the employer or its workers compensation insurer will issue a response of either approval, denial, or approval with modification of the requested treatment on the Form LWC-WC-1010 and return the form to the requesting health care provider. Failure to act on behalf of the employer or its workers compensation insurer within five business days of receipt of the Form LWC-WC 1010 will be deemed a tacit denial of the request for treatment and this denial may be reviewed by the OWCA Medical Director.
• The employer or its workers compensation insurer and/or utilization review representative may initiate the Form LWC-WC-1010A (First Request) when the medical documentation submitted with the Form LWC-WC-1010 does not sufficiently provide the necessary information to complete the review of the requested medical services. The health care provider must then respond to the request for additional information within ten business days from receipt of the Form LWC-WC-1010A. Failure to act on behalf of the health care provider within the ten business days of receipt of the Form LWC-WC 1010A will be deemed a tacit withdrawal of the request for authorization of treatment.
• Any request for review by the OWCA Medical Director shall be filed on a Form LWC-WC 1009 (Disputed Claim for Medical Treatment). The Form LWC-WC 1009 must be filed within 15 calendar days of the date of denial by the employer or its workers compensation insurer or the date the denial is received. A copy of the completed Form LWC-WC 1009 must be mailed to all involved parties.
• The Form LWC-WC 1009 must be accompanied by a copy of the Form LWC-WC 1010 (and Form LWC-WC 1010A, if applicable), a copy of the peer review denial from the employer and/or its workers compensation insurer, and a copy of the medical records substantiating the medical necessity of the requested treatment. Any incomplete Form LWC-WC 1009 or a completed Form LWC-WC 1009 that is not submitted with the supporting documentation will be rejected and returned to the requesting party.
• Within 30 days after receipt of the Form LWC-WC 1009 and supporting documentation, the OWCA Medical Director will determine whether the treatment prescribed by the health care provider is in accordance with the Louisiana Workers Compensation Medical Treatment Guidelines. Any party feeling aggrieved by the determination of the OWCA Medical Director shall seek a judicial review by filing a Form LWC-WC 1008 (Disputed Claim for Compensation) with the appropriate OWCA district office within 15 days of the date of said determination is mailed to the parties. The filed Form LWC-WC 1008 shall include a copy of the Form LWC-WC 1009, and a copy of the determination of the OWCA Medical Director. A party filing such appeal must simultaneously notify the other party that an appeal of the medical director’s decision has been filed. The determination of the OWCA Medical Director may be overturned if it is shown by clear and convincing evidence that the determination was not in accordance with the provisions of the Louisiana Workers Compensation Medical Treatment Guidelines.

A Simpler Overview of The Utilization Review Process

A simpler overview of the Utilization Review process for paying workers compensation medical claims is as follows:

• The process begins with the health care provider (who is seeking authorization for over $750 of medical services) submitting a request to the workers compensation insurer on a Form LWC-WC 1010 (Request of Authorization/Carrier or Self Insured Employer Response). The Form LWC-WC 1010 and all supporting medical documentation are to be faxed to the workers compensation insurer and/or the designated utilization review representative.
• Within five business days of receipt of the Form LWC-WC 1010, the workers compensation insurer will issue a response of either approval, denial, or approval with modification of the requested treatment on the Form LWC-WC-1010 and return the form to the requesting health care provider. 
• The workers compensation insurer and/or utilization review representative may send a Form LWC-WC-1010A (First Request) when the medical documentation submitted with the Form LWC-WC-1010 is not sufficient to complete the review for the requested medical services.
• The health care provider must then respond to the request for additional information within ten business days from receipt of the Form LWC-WC-1010A.
• If the workers compensation insurer denies the requested treatment or does not respond within five days, then within 15 calendar days of the date of denial, the health care provider must file a Form LWC-WC 1009 (Disputed Claim for Medical Treatment) to request a review by the OWCA Medical Director. The Form LWC-WC 1009 must be accompanied by a copy of the Form LWC-WC 1010 (and Form LWC-WC 1010A, if applicable), and a copy of the supporting medical records.
• Within 30 days after receipt of the Form LWC-WC 1009 and supporting documentation, the OWCA Medical Director will render a decision as to whether the medical treatment should be approved.
• Any party who disagrees with the decision of the OWCA Medical Director can seek a judicial review by filing a Form LWC-WC 1008 (Disputed Claim for Compensation) with the appropriate OWCA district office within 15 days of the date on which the Medical Director’s decision is mailed to the parties. The filed Form LWC-WC 1008 shall include a copy of the Form LWC-WC 1009, and a copy of the determination of the OWCA Medical Director. An expedited hearing will be held within 15-30 days, and the decision of the OWCA Medical Director may be overturned if it is shown by clear and convincing evidence that the determination was not in accordance with the Medical Treatment Guidelines.

Forms Used in The Utilization Review Process in Louisiana Workers Compensation

Far and away, the forms most used in the Louisiana workers compensation Utilization Review process are Form 1010, Form 1010A, Form 1009, and Form 1008.

The 1010 and 1010 a Forms in The Utilization Review Process

The process for approving medical treatments for an injured employee begins with the health-care provider completing the LWC-WC Form 1010 when the provider is seeking authorization to exceed the $750 statutory limit for medical services.

A copy of the actual LWC-WC Form 1015 is available here.

The health-care provider requesting approval must complete Section #1 and Section #2 of the LWC-WC Form 1010, and then fax the LWC-WC Form 1010 and all supporting medical documentation to the workers compensation insurance company and/or its designated Utilization Review representative.

The LWC-WC Form 1010 requires the following information:

• History provided to the level of condition and as provided by Medical Treatment Schedule
• Physical Findings/Clinical Tests
• Documented functional improvements from prior treatment
• Test/imaging results
• Treatment Plan including services being requested along with the frequency and duration

The workers compensation insurance company and/or its designated Utilization Review representative must respond within five business days by returning the LWC-WC Form 1010 to the requesting health-care provider with its decision determination regarding approval designated in Section 3.

If the workers compensation insurance company and/or its designated Utilization Review representative claims that the medical documentation submitted with the LWC-WC Form 1010 does not sufficiently provide the necessary information to complete the review of the requested medical services, it must complete and send the LWC-WC Form 1010A to the health care provider.

A copy of the actual LWC-WC Form 1010A is available here.

The health-care provider must respond to the LWC-WC Form 1010A request within ten business days from the date of receipt.

If the health-care provider fails to submit the requested medical information, that inaction shall result in a withdrawal of the request for authorization.

At this point, the workers compensation insurance company can either approve or deny the requested medical treatment.

Form 1009: The Dispute Goes to The Medical Director

If the workers compensation insurance company has denied the medical treatment requested by the health care provider or does not respond within five days, the decision can be appealed to the OWC Medical Director by filing a Form LWC-WC 1009 (Disputed Claim for Medical Treatment) within 15 calendar days of the date of denial.

A copy of the actual LWC-WC Form 1009 is available here.

“Any aggrieved party” can file this Form LWC-WC 1009 Disputed Claim. An aggrieved party is defined as “a person whose personal or property rights are adversely affected by a judgment or decree of a court.”

Typically, the aggrieved party filing a Form LWC-WC 1009 is either the health care provider or the injured employee.

In addition to the completed LWC-WC Form 1009, the following information must also be submitted, via mail, to the OWCA Medical Director:

• A copy of the LWC-WC Forms 1010 and 1010A;
• A copy of the denial from workers compensation insurance company and/or its designated Utilization Review representative; and
• A copy of the medical records substantiating the medical necessity of the requested services.

In fact, a copy of the completed LWC-WC Form 1009 and supporting documentation must be mailed to all parties.

Requests submitted without the complete proper supporting documentation will be returned to the requesting party, as will any LWC-WC Form 1009 with incomplete information.

The OWCA Medical Director will render a decision as soon as is practicable, but in no event, not more than 30 calendar days from the date of filing.

Form 1008: The Dispute Goes to The Owc Judge

Any party who disagrees with the decision of the OWCA Medical Director can seek a review by the workers compensation district Judge by filing a Form LWC-WC 1008 (Disputed Claim for Compensation) with the appropriate OWCA district office within 15 days of the date of which the Medical Director’s decision is mailed to the parties.

A copy of the actual LWC-WC Form 1008 is available here.

The filed LWC-WC-1008 shall include the following:

• A copy of the Form LWC-WC-1009 – Disputed Claim for Medical Treatment; and
• A copy of the decision of the medical director.

The party that is filing the LWC-WC-1008 must simultaneously notify the other parties that an appeal of the medical director’s decision has been filed.

Also, “any aggrieved party” can file this Form LWC-WC 1008 Disputed Claim.

An aggrieved party is defined as “a person whose personal or property rights are adversely affected by a judgment or decree of a court.”

Typically, the aggrieved party filing a Form LWC-WC 1008 is either the health care provider, the injured employee, the employer, the workers compensation insurance company, or the insurance company’s designated Utilization Review representative.

An expedited hearing will be held within 15-30 days, and the decision of the OWCA Medical Director may be overturned by the OWC Judge if it is shown by clear and convincing evidence that the determination was not in accordance with the Medical Treatment Guidelines.

If any party disagrees with the decision of the OWC Judge, that party can appeal the decision to the circuit court of appeal for the judicial district in which the hearing was held.

The Louisiana Statutes for Approval of Health Care Providers and Fees in Louisiana Workers Compensation

The Louisiana statutes controlling the approval of health care providers and their expenses and fees are La. R.S. 23:1142, La. R.S. 23:1203, and La. R.S. 23:1203.1, which read as follows:

§1142.  Approval of health care providers; fees

A.  Definitions.  For the purposes of this Section, the following terms shall have the following meanings unless the context clearly indicates otherwise:

(1)  “Payor” shall mean the entity responsible, whether by law or contract, for the payment of the medical expenses incurred by a claimant as a result of a work-related injury.

(2)  “Utilization review company” shall mean the company or entity which contracts with the payor, and which entity reviews the claimant’s medical records and information and makes the determination of medical necessity in accordance with this Chapter, for the purposes of assisting the payor with the authorization of the claimant’s medical care, services, and treatment requested pursuant to this Chapter.

B.  Nonemergency care.

(1)(a)  Except as provided herein, each health care provider may not incur more than a total of seven hundred fifty dollars in nonemergency diagnostic testing or treatment without the mutual consent of the payor and the employee as provided by regulation.  Except as provided herein, that portion of the fees for nonemergency services of each health care provider in excess of seven hundred fifty dollars shall not be an enforceable obligation against the employee or the employer or the employer’s workers compensation insurer unless the employee and the payor have agreed upon the diagnostic testing or treatment by the health care provider.

(b)(i) The payor may contract with a utilization review company to assist the payor in determining if the request for nonemergency diagnostic testing or treatment, in an amount which exceeds seven hundred fifty dollars, is a medical necessity as provided pursuant to this Chapter.

(ii)  A medical necessity determination by a utilization review company and the payor’s consent to authorize the requested nonemergency diagnostic testing and treatment shall require only a review of the claimant’s medical records and shall not require an examination of the employee.

(2)(a)  When the payor has agreed to the diagnostic testing or treatment, the health care provider shall not issue any demand for payment to the employee or his family until the payor denies liability for the diagnostic testing or treatment.  Notwithstanding the foregoing, the health care provider may reasonably communicate with the employee or his attorney or representative for the purpose of pursuing its claim against the payor.

(b)  A health care provider who knowingly and willfully violates this Paragraph may be ordered by the workers compensation judge to pay penalties not to exceed two hundred fifty dollars per violation plus reasonable attorney fees.  The penalty shall not exceed one thousand dollars for any demand for payment to an employee or his family which is issued after the health care provider has been penalized for a previous demand for payment to that employee or his family.

C.  Emergency care.

(1)  In no event shall prior consent be required for any emergency procedure or treatment deemed immediately necessary by the treating health care provider.  Any health care provider who authorizes or orders emergency diagnostic testing or treatment, when said diagnostic testing or treatment is held not to have been of an emergency nature, shall be responsible for all of the charges incurred in such diagnostic testing or treatment.  Said health care provider shall bear the burden of proving the emergency nature of the diagnostic testing or treatment.

(2)  Fees for those services of the health care provider held not to have been of an emergency nature shall not be an enforceable obligation against the employee or the employer or the employer’s workers compensation insurer unless the employee and the payor have agreed upon the treatment or diagnostic testing by the health care provider, except as provided in R.S. 23:1272(D).

D.  Fees and expenses.  If the payor has not consented to the request to incur more than a total of seven hundred fifty dollars for any and all nonemergency diagnostic testing or treatment when such consent is required by this Section, and it is determined by a court having jurisdiction in an action brought either by the employee or the health care provider that the withholding of such consent was arbitrary and capricious, or without probable cause, the employer or the insurer shall be liable to the employee or health care provider bringing the action for reasonable attorney fees related to this dispute and to the employee for any medical expenses so incurred by him for an aggravation of the employee’s condition resulting from the withholding of such health care provider services.

E.  Exception.  In the event that the payor has denied that the employee’s injury is compensable under this Chapter, then no approval from the payor is required prior to the provision of any diagnostic testing or treatment for that injury.

Acts 1988, No. 617, §1; Acts 1995, No. 1137, §1, eff. June 29, 1995; Acts 1997, No. 1472, §1; Acts 2012, No. 235, §1.

§1203. Duty to furnish medical and vocational rehabilitation expenses; prosthetic devices; other expenses

A. In every case coming under this Chapter, the employer shall furnish all necessary drugs, supplies, hospital care and services, medical and surgical treatment, and any nonmedical treatment recognized by the laws of this state as legal, and shall utilize such state, federal, public, or private facilities as will provide the injured employee with such necessary services. Medical care, services, and treatment may be provided by out-of-state providers or at out-of-state facilities when such care, services, and treatment are not reasonably available within the state or when it can be provided for comparable costs.

B. The obligation of the employer to furnish such care, services, treatment, drugs, and supplies, whether in state or out of state, is limited to the reimbursement determined to be the mean of the usual and customary charges for such care, services, treatment, drugs, and supplies, as determined under the reimbursement schedule annually published pursuant to R.S. 23:1034.2 or the actual charge made for the service, whichever is less. Any out-of-state provider is also to be subject to the procedures established under the office of workers compensation administration utilization review rules.

C. The employer shall furnish to the employee the necessary cost of repair to or the replacement of any prosthetic device damaged or destroyed by accident in the course and scope and arising out of such employment, including but not limited to damage or destruction of eyeglasses, artificial limbs, hearing aids, dentures, or any such prosthetic devices whatsoever.

D. In addition, the employer shall be liable for the actual expenses reasonably and necessarily incurred by the employee for mileage reasonably and necessarily traveled by the employee in order to obtain the medical services, medicines, and prosthetic devices, which the employer is required to furnish under this Section, and for the vocational rehabilitation-related mileage traveled by the employee at the direction of the employer. When the employee uses his own vehicle, he shall be reimbursed at the same rate per mile as established by the state of Louisiana for reimbursement of state employees for use of their personal vehicle on state business. The office shall inform the employee of his right to reimbursement for mileage.

E. Upon the first request for authorization pursuant to R.S. 23:1142(B)(1), for a claimant’s medical care, service, or treatment, the payor, as defined in R.S. 23:1142(A), shall communicate to the claimant information, in plain language, regarding the procedure for requesting an additional medical opinion regarding a medical examination in the event a dispute arises as to the condition of the employee or the employee’s capacity to work, and the procedure for appealing the denial of medical treatment to the medical director as provided in R.S. 23:1203.1. A payor shall not deny medical care, service, or treatment to a claimant unless the payor can document a reasonable and diligent effort in communicating such information. A payor who denies medical care, service, or treatment without making such an effort may be fined an amount not to exceed five hundred dollars or the cost of the medical care, service, or treatment, whichever is more.

Amended by Acts 1952, No. 322, §1; Acts 1956, No. 282, §1; Acts 1968, No. 103, §1; Acts 1975, No. 583, §6, eff. Sept. 1, 1975; Acts 1976, No. 400, §1; Acts 1977, No. 530, §1. Acts 1983, 1st Ex. Sess., No. 1, §1, eff. July 1, 1983; Acts 1987, No. 290, §1; Acts 1988, No. 938, §1, eff. Jan. 1, 1989; Acts 1989, No. 260, §1, eff. June 26, 1989; Acts 1997, No. 452, §1, eff. June 22, 1997; Acts 2001, No. 898, §1; Acts 2012, No. 235, §1; Acts 2017, No. 381, §2, eff. June 23, 2017.

§1203.1. Definitions; medical treatment schedule; medical advisory council

I. After the promulgation of the medical treatment schedule, throughout this Chapter, and notwithstanding any provision of law to the contrary, medical care, services, and treatment due, pursuant to R.S. 23:1203 et seq., by the employer to the employee shall mean care, services, and treatment in accordance with the medical treatment schedule. Medical care, services, and treatment that varies from the promulgated medical treatment schedule shall also be due by the employer when it is demonstrated to the medical director of the office by a preponderance of the scientific medical evidence, that a variance from the medical treatment schedule is reasonably required to cure or relieve the injured worker from the effects of the injury or occupational disease given the circumstances.

J.(1) After a medical provider has submitted to the payor the request for authorization and the information required by the Louisiana Administrative Code, Title 40, Chapter 27, the payor shall notify the medical provider of their action on the request within five business days of receipt of the request. If any dispute arises after January 1, 2011, as to whether the recommended care, services, or treatment is in accordance with the medical treatment schedule, or whether a variance from the medical treatment schedule is reasonably required as contemplated in Subsection I of this Section, any aggrieved party shall file, within fifteen calendar days, an appeal with the office of workers compensation administration medical director or associate medical director on a form promulgated by the assistant secretary. The medical director or associate medical director shall render a decision as soon as is practicable, but in no event, not more than thirty calendar days from the date of filing.

(2) If either party, the medical director, or associate medical director believes that a potential conflict of interest exists, he shall communicate in writing such information to the assistant secretary, who shall make a determination as to whether a conflict exists within two business days. The assistant secretary shall notify in writing the patient, the physician, and, if applicable, the attorney of his decision within two business days.

K. After the issuance of the decision by the medical director or associate medical director of the office, any party who disagrees with the decision, may then appeal by filing a “Disputed Claim for Compensation”, which is LWC Form 1008. The decision may be overturned when it is shown, by clear and convincing evidence, the decision of the medical director or associate medical director was not in accordance with the provisions of this Section.

L. It is the intent of the legislature that, with the establishment and enforcement of the medical treatment schedule, medical and surgical treatment, hospital care, and other health care provider services shall be delivered in an efficient and timely manner to injured employees.

Acts 2009, No. 254, §1; Acts 2010, No. 619, §1, eff. June 25, 2010; Acts 2012, No. 573, §1; Acts 2012, No. 811, §6, eff. July 1, 2012; Acts 2013, No. 317, §1; Acts 2014, No. 791, §9; Acts 2018, No. 380, §1, eff. June 30, 2018.