Medical Treatment

Since 2011, Louisiana has made several changes to the procedures injured workers and their treating physicians must follow to seek payment medical expenses under the Louisiana Workers Compensation Act.

According to the Louisiana Office of Workers Compensation Rights & Responsibilities Update posted as of August, 2015 on the Louisiana Department of Labor Office of Workers Compensation’s website, the procedure for workers compensation medical claims falling under the Louisiana Workers Compensation Act is 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.
• Under La. R.S. 23:1142(B), a health care provider may not incur more than $750 in total for nonemergency diagnostic testing or treatment without the mutual consent of the payor and the employee. That limit is a cumulative total per provider, not a threshold applied to each individual service. Non-emergency hospitalization must also be pre-approved. Two exceptions matter: no prior consent is required for emergency care the provider judges immediately necessary, La. R.S. 23:1142(C); and no approval is required at all where the payor has denied that the injury is compensable, La. R.S. 23:1142(E). 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.
• Once a properly completed request is submitted, the payor must notify the provider of its action within five business days. La. R.S. 23:1203.1(J). A party who disputes that decision has fifteen calendar days to appeal to the Office of Workers’ Compensation medical director, who must rule within thirty calendar days. The fifteen days run from the health care provider’s receipt of the Form LWC-WC 1010 denying the request or approving it with modification, or, where the payor did not respond at all, from expiration of the fifth business day it had to act. La. Admin. Code tit. 40, § I-2715(J)(1).
• 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, by fax or email, to that first request for additional information within 10 business days of receiving the Form LWC-WC-1010A. La. Admin. Code tit. 40, § I-2715(E)(1)(a). Failure to act on behalf of the health care provider within the 10 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, and the 15 days run from one of two events depending on what the payor did. Where the payor responds, the period runs from the health care provider’s receipt of the Form LWC-WC 1010 denying the treatment or approving it with modification. Where the payor does not respond at all, the period runs from the expiration of the fifth business day it had to act, that silence being itself a denial. La. Admin. Code 40:I.2715(J)(1). 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 forty-five days of the date the determination is issued. La. R.S. 23:1203.1(K). Note that the implementing regulation has not been conformed to the amended statute: La. Admin. Code tit. 40, § I-2715(B)(3)(f) and (K)(1) still state fifteen days from the date the decision is mailed. The statute provides forty-five days; the published rule still provides fifteen. A party appealing should act promptly and take advice on the particular case rather than rely on the longer period. This deadline is also separate from the fifteen calendar days allowed for appealing a payor’s denial to the Medical Director, described above. The filed Form 1008 workers’ compensation Louisiana 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.