La. Admin. Code tit. 40 § I-2703

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-2703 - Introduction

A. Managed care activities are defined as a set of coordinated cost and utilization management activities by the carrier/self-insured employer to assure appropriate payment for health care services rendered to employees eligible for workers' compensation benefits in the state of Louisiana.

1. Pre-admission certification review is the cornerstone of utilization management. The pre-admission certification review notice (i.e., telephone call or written notification) is the claimant's entry into the benefits management system and triggers other utilization management functions. During pre-admission certification review, all utilization management activities can be coordinated. When cases are reviewed before hospitalization, this activity works to promote appropriate lengths of stay, discharge planning, and ambulatory care. The pre-admission certification program reviews and certifies, before hospitalization, that a proposed hospital admission is both medically necessary and appropriate. It is not a process of substituting judgement for that of the physician, but rather making a determination of what level of care is to be reasonable and necessary under the provisions of the Louisiana Workers' Compensation Act.

2. The following managed care activities required by the Louisiana Workers' Compensation Act are described: pre-admission certification, admission certification, continued stay review (including length of stay assignment), discharge planning, reporting standards and dispute resolution, ambulatory surgery, and second surgical opinion.

B. Definitions

Admission Review- the review of the medical necessity and appropriateness of hospital admissions. The review takes place after the admission, but within a stated time frame.

Ambulatory Review- the review of the medical necessity and appropriateness of services rendered to claimants in out-of-hospital settings (e.g., skilled nursing facility, home health services, physician's office, and outpatient ancillary services).

Appeals Process- a physician, hospital, or a claimant may appeal to the carrier/self-insured employer to change its decision regarding payment for an inpatient admission, an extension of a length of stay, a specific treatment or for a claim for medical services. The appeals process is formally written and includes specific time frames, how the process works and who makes the final decision. The final step in the appeals process is a review by the Office of Workers' Compensation Administration.

Continued Stay Review- the review of an ongoing inpatient hospitalization to assure that it remains the most appropriate setting for the care being rendered.

Discharge Planning- the process of assessing a claimant's need for medically appropriate treatment after hospitalization to effect an appropriate and timely discharge. The hospital and attending physician have major responsibility for this function with the carrier/self-insured employer promoting, monitoring, and assisting the hospital.

Pre-Admission Certification Review- the review and assessment of the medical necessity and appropriateness of hospital admissions before hospitalization occurs. The appropriateness of the site or level of care is assessed along with the timing and duration of the proposed hospitalization.

Second Surgical Opinion- second surgical opinion programs enable claimants to receive a consultation from a second physician before undergoing specified surgical procedures. The consulting opinion does not have to confirm the original recommendation for surgery, however, the decision to have or not to have the surgery remains with the claimant.

Utilization Management Program- a comprehensive set of integrated utilization management components including: pre-admission certification review, admission review, second surgical opinion, continued stay review, and discharge planning.

La. Admin. Code tit. 40, § I-2703

Promulgated by the Department of Employment and Training, Office of Workers' Compensation, LR 17:263 (March 1991), repromulgated LR 17:653 (July 1991).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1291.