WORKERS' COMPENSATION: Provides relative to the workers' compensation reimbursement schedule. (gov sig) (EN INCREASE SD EX See Note)

The definition of 'By report' (a prohibited reimbursement method) was removed and replaced with a new definition of 'Payor' as the entity responsible by law or contract for payment of medical expenses from a work injury or occupational disease.

The reimbursement schedule basis changed from the 75th percentile of the Practice Management Information Corporation Medical Fees Directory (for CPT-coded services) to the mean of usual and customary charges, with annual adjustments permitted. A new implant reimbursement formula was added: manufacturer's invoice plus 20 percent.

New data collection guidelines were added for calculating the reimbursement schedule, including requirements for a written survey managed with an academic institution, minimum 30 providers per statistic, no single provider exceeding 25 percent weighted influence, and aggregation to prevent identification of individual providers. Violation of confidentiality is a misdemeanor punishable by up to $500 fine.

A dental services reimbursement cap was added: not to exceed the 70th percentile in the current edition of the National Dental Advisory Service Comprehensive Fee Report using Louisiana geographic multipliers.

A new preliminary determination hearing process was added for controverted compensation and medical benefits. Employers or payors may request this hearing in their answer to a disputed claim. Hearings must be held within 90 days of the scheduling conference (one 30-day extension allowed), with decisions issued within 30 days after the hearing. Non-compliance with a preliminary determination exposes the employer or payor to penalties and attorney fees at trial on the merits.

Notice requirements for modification, suspension, termination, or controversion of benefits were significantly expanded. Employers must now prepare a specific notice form (LWC-WC 1002), send it by certified mail to the employee's payment address on or before the effective date, and provide copies to the office and the employee's attorney. A seven-business-day waiting period was extended to ten business days before an employee may file a disputed claim.

The dispute resolution process for billing disputes was simplified from a four-level process (office decision, appeal to assistant secretary with independent reviewer, then Nineteenth Judicial District Court) to a two-level process: office decision within 15 business days, then appeal to the judicial district court within 30 days. The nonprevailing party pays review costs and 12 percent annual interest applies if a denied claim is later paid.

The original civil fine structure for late payment of medical benefits ($1,000 to $5,000 per violation, and $25,000+ for willful violations) was removed from Section 1201(E) and replaced with a reference to fines and interest under R.S. 23:1034.2(F). The penalty cap of $8,000 aggregate per claim and $2,000 maximum daily penalty were retained in the general penalty provisions.

Prior authorization timelines were restructured. The original specified 7 business days for surgical procedures (5 for urgent neurological cases) and 10 business days for specialist referrals. The enrolled version uses a general 5-business-day response requirement, with certain requests (office visits, diagnostic testing, chiropractic or physical therapy of 12 visits or less) deemed authorized if not specifically denied within 5 business days.

The new subpart establishing the database was renumbered from R.S. 23:1200.18 through 1200.26 to R.S. 23:1200.18.1 through 1200.18.9, and the database name changed from 'All Workers' Compensation Medical Claims Database' to 'All Workers' Compensation Medical Bill Database' throughout the bill.

The document status changed from 'Re-Engrossed' to 'Enrolled Act No. 766', indicating the bill has passed all legislative stages and is now law.

Minor adjustments were made to the list of amended statutes and the summary of the bill's purpose to ensure accurate citation of the final enacted laws.

Formatting changes were applied to the definitions section, specifically updating the definition of 'Payor' and reorganizing the reimbursement schedule clauses for clarity and finality.

The dispute resolution process description was slightly refined to clarify that disputes regarding billing and payment must be submitted to the office of workers' compensation administration's medical services section.

Added a new requirement for the office of workers' compensation administration to review and update all fee schedules every two years.

Updated the reference for the fee decrease phase-in provision from Subparagraph (3)(a) to Subparagraph (4)(a) to align with the correct section numbering.

Adjusted the document header and the definition of 'Payor' to reflect the reengrossed status and standardize quotation mark usage.

Added a new definition for 'Payor' to clarify the entity responsible for paying medical expenses related to work injuries.

Updated the list of amended statutes to include '1203.1(J)(1)' and added a new subsection (15) to the terms defined section.

Adjusted the page count reference from 21 to 23 to reflect the addition of new content.

Deleted the mandate to establish an 'All Workers' Compensation Medical Bill Database' and the requirement for mandatory reporting of medical and pharmacy claims data.

Removed the provision requiring the collection of information and data to calculate the reimbursement schedule.

Added an explicit prohibition against reimbursing services 'by report' when a provider does not have an established maximum fee allowance.

Added a new definition for 'By report' to clarify the prohibited reimbursement method.

Changed the bill header from 'ENROLLED' to 'ORIGINAL' and renumbered the bill text.