La. Admin. Code tit. 40 § I-2719

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

Section I-2719 - Instructions for On-Site Audit of Hospital Charges by Workers' Compensation Carrier

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.

2. Hospital Responsibilities

a. Hospitals must schedule an appointment to audit a bill promptly upon the receipt of a request for such an appointment, at a time mutually agreed upon by the hospital and the carrier/self-insured employer or its audit agency no later than 10 days from receipt of request.

b. Hospitals should respond promptly to a request for an itemized bill from the carrier/self-insured employer or its agent.

c. Hospitals should respond promptly to requests for additional information on the period of hospitalization, including information from the medical record and from the billing office.

d. Hospitals should designate one individual to be responsible for coordinating all hospital audit activities, and act as a liaison between provider personnel and the carrier/self-insured employer. This would include informing appropriate hospital departments of pending audits and audit results, answering carrier/self-insured employer questions, insuring that a late charge bill is sent to the patient or carrier/self-insured employer, issuing a refund to the appropriate party, etc. After notice of a proposed audit has been received by the hospital, this individual should coordinate between the medical records department and the billing office to insure that medical records, financial records, and any other documentation needed to substantiate charges are provided and available for the audit.

e. The hospital liaison shall acquaint the carrier/self-insured employer representative or audit agent with its record system and charging practices.

f. All substances administered to the patient in any form, as well as all treatments or medical services, must be specifically and accurately documented.

g. The hospital's representative will be available to the carrier/self-insured employer to conduct an exit interview. Discrepancies will be reviewed, resolved, and agreed upon by both parties. This will be done by written confirmation of the unbilled and/or undocumented charges identified during the audit and signed by both parties. In the event that same day resolution is not possible, the hospital, in a timely manner, should resolve differences in any unsupported or unbilled amounts resulting from the audit.

h. The hospital should issue refunds promptly if overcharges and/or undocumented charges exceeding the balance of the carrier/self-insured employer liability are discovered during the audit.

i. Hospitals may not bill for undocumented charges discovered during the bill audit process. However, hospitals may bill for documented and previously unbilled charges discovered during the bill audit process, for charges in excess of the audit fee charged by the hospital.

La. Admin. Code tit. 40, § I-2719

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.