La. Admin. Code tit. 40 § I-2717

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

Section I-2717 - Medical Review Guidelines

A. Workers' Compensation is designed to provide indemnity and medical care benefits for workers who sustain injuries or illnesses arising out of and in the course and scope of employment. The following instructions give some general guidelines for medical review of workers' compensation claims.

B. Technical Considerations for Review of Claims

1. Prior to a detailed medical review, a cursory review of the claim should be accomplished and should include at least the following.

a. Job related illness/injury must be identified.

b. Each service/item billed must be identifiable.

c. Billing period must be identified.

d. Appropriate forms must be used and filled out completely.

2. If the cursory review indicates that sufficient information is present, processing of the claim can proceed. If the review indicates information is lacking, the carrier/self-insured employer must take immediate and appropriate action to obtain the information required. The "timely payment" provision contained in the statement of policy in this manual will not apply until the required information is obtained. However, absence of nonessential information is not justification for delay in claim processing.

C. Functions of Medical Review. The carrier/self-insured employer should use a program of prevention and detection to guarantee the most appropriate and economical use of health care resources for claimants.

1. Prevention through Education. Informing physicians and other health care providers about workers' compensation programs, policies and statutory provisions that deal with claim submission is the key to ensuring the appropriate billing of covered services. As part of that educational focus, the following are some of the administrative policies encountered in the review process:

a. quality of care;

b. medical necessity;

c. screening tests;

d. confidentiality;

e. general documentation requirements.

2. Quality of Care. Quality care should:

a. be provided in a timely manner, without inappropriate delay, interruption, premature termination or prolongation of treatment, and emphasize an early, safe return to work;

b. seek the patient's cooperation and participation in the decisions and process of his or her treatment;

c. be based on accepted principles of evidence based practice as established in R.S. 23:1203.1 and the skillful and appropriate use of other health professionals and technology;

d. be provided with sensitivity to the stress and anxiety that illness can cause, and with concern for the patient's and family's overall welfare and should focus on improvement in function related to the physical demands of the injured workers job;

e. use technology and other resources efficiently to achieve the treatment goal;

f. be sufficiently documented in the patient's medical record to allow continuity of care and peer evaluation.

3. Medical Necessity

a. The workers' compensation law provides benefits only for services that are medically necessary for the diagnosis or treatment of a claimant's work related illness, injury, symptom or complaint. Medically necessary or medical necessity shall mean health care services that are:

i. clinically appropriate, in terms of type, frequency, extent, site, and duration, and effective for the patients illness, injury, or disease; and

ii. in accordance with the medical treatment schedule and the provisions of R.S. 23:1203.1.

b. To be medically necessary, a service must be:

i. consistent with the diagnosis and treatment of a condition or complaint; and

ii. in accordance with the Louisiana medical treatment schedule; and

iii. not solely for the convenience of the patient, family, hospital or physician; and

iv. furnished in the most appropriate and least intensive type of medical care setting required by the patient's condition.

c. Services not related to the diagnosis or treatment of a work related illness or injury are not payable under the workers' compensation laws and shall be the financial responsibility of the claimant, and in appropriate cases, his health insurance carrier.

4. Screening Tests

a. A screening test not related to the on-the-job illness or injury is not covered under the workers' compensation law.

b. A screening test may be defined as a diagnostic procedure or test which is performed for a claimant in the absence of, or regardless of, his/her presenting sign(s), complaint(s), or symptom(s).

c. Although screening tests may reflect good medical practice, such tests are not covered under the Workers' Compensation Program if not specifically related to the on-the-job illness or injury. For example, a standard battery of laboratory tests ordered without regard to a specific symptom or diagnosis consistent with the reported on-the-job illness or injury, is considered nonpayable screening.

d. Payment for such test(s) shall be an enforceable obligation against the claimant and, in appropriate cases, his health insurance carrier, but shall not be an enforceable obligation against the employer or insurer.

5. Confidentiality. When it is necessary to request additional information to clarify the need for services or substantiate coverage for a claim being reviewed, the carrier/self-insured employer must take particular care to ensure that all of its employees adhere to strict policy guidelines regarding claimant privacy. The carrier/self-insured employer shall require only sufficient information to allow a reviewer to make an independent judgement regarding diagnosis and treatment. Intimate details in a claimant's records are neither necessary nor desired, and are specifically protected by law.

6. General Documentation Requirements. The determination of appropriate reimbursement requires adequate documentation of services. The following items establish the minimum documentation requirements prior to payment.

a. Documentation for all services must be legible and signed by the health care provider, i.e., date(s) of service, type of surgery where applicable, diagnosis (not a list of symptoms).

b. Submitted documentation must contain sufficient data to substantiate the diagnosis and need for treatment on each date of service.

c. To substantiate medical necessity:

i. it is essential to report the most complete and precise diagnosis(es) on the claim form;

ii. service(s) billed should be appropriate for the diagnosis;

iii. documentation in the clinical record (i.e., physical findings and historical data) should confirm the diagnosis and support the medical necessity and appropriateness of the service billed; and

iv. documentation should be available for each service billed.

d. The maintenance of adequate and accurate clinical records is a requirement for all physicians and hospitals. Documentation should be complete, including positive as well as negative findings, and should be recorded in a timely manner.

7. Detection. The carrier/self-insured employer detects the misuse of benefits through routine claims review, computer analysis, claims audit and the investigation of complaints. The carrier shall conduct such reviews and analysis on an ongoing basis and shall investigate all complaints in a timely manner. Referrals of appropriate cases may be made to the Office of Workers' Compensation Medical Review staff.

8. Prepayment and Postpayment Claim Review. A practitioner's or provider's claims may be selected for review by the Office of Workers' Compensation if utilization review procedures detect a pattern of over-utilization of services. If a review indicates a possible overuse or misuse of services, the practitioner or provider will be notified in writing that he or she will receive a request for additional information on a sampling of submitted claims.

9. Referrals. The Office of Workers' Compensation medical review staff will investigate complaints from claimants, carriers, employers, physicians, other practitioners, and health care facilities, inquiries from the press or government agencies, referrals from other internal areas of the Office of Workers' Compensation, and even leads from various media sources (e.g., newspapers) if in the judgement of the medical manager such investigation is warranted. In appropriate cases, the Office of Workers' Compensation will refer evidence of over-utilization to the various licensing authorities.

D. Professional Justification

1. Medical Necessity. All claims submitted for payment to the carrier/self-insured employer must be reviewed for medical necessity and for compliance with the medical treatment schedule and the provisions of R.S. 23:1201.1. Medical necessity implies the use of technologies* services, or supplies provided by a hospital, physician, or other provider that is determined to be:

a. medically appropriate for the symptoms and diagnosis or treatment of the work-related illness or injury;

b. provided for the diagnosis or the direct care and treatment of the patient's illness or injury;

c. in accordance with the medical treatment schedule and the provisions of R.S. 23:1203.1; and

d. not primarily for the convenience of the patient, patient's family, practitioner or provider; and

e. the most appropriate level of service that can be provided to the patient.

2. Additional Medical Record Information. It is the responsibility of the claimant and provider to furnish all medical documentation needed by the carrier/self-insured employer to determine if the injury or illness is job related and if the services are medically necessary for the condition of the claimant (e.g., physician office record, hospital medical record, doctor's orders, treatment plan, vital signs, lab data, test results, nurses' notes, progress notes).

*The term technology refers to any medical or surgical treatment, medical or surgical device, therapeutic or diagnostic procedure, drug, biological, or therapeutic or diagnostic agent.

La. Admin. Code tit. 40, § I-2717

Promulgated by the Department of Employment and Training, Office of Workers' Compensation, LR 17:263 (March 1991), repromulgated LR 17:653 (July 1991), amended by the Louisiana Workforce Commission, Office of Workers' Compensation, LR 38:1036 (April 2012), repromulgated LR 38:1293 (May 2012).

AUTHORITY NOTE: Promulgated in accordance with RS 23:1291.