(c)13 TheOn informationpage requested7, shallline be24, basedchange upon"(6)" datato at"(5)" leastAMENDMENT sixNO. months old.

(d)14 ThereOnpage8,deletelines12through23intheirentiretyandinsertinlieuthereofthefollowing: shall be a minimum of thirty health care providers reporting data upon which each disseminated statistic is based.

Page"(2) 2Failureto ofpay 24medicalbenefitsas Coding:requiredby this Subsection shall be subject to potential fines and interest pursuant to R.S.

Words which are struck through are deletions from existing law;

words in boldface type and underscored are additions.

SB NO.

408 ENROLLED (e) No individual health care provider's data shall represent more than twenty-five percent on a weighted basis of each statistic.

(f) Any information disseminated shall be sufficiently aggregated such that itwillnotallowrecipientstoidentifythepriceschargedorcompensationpaidbyany particular health care provider.

(3)AllinformationcollectedpursuanttothisSubsectionshallbeconfidential andprivileged,shallnotbepublicrecord,andshallnotbesubjecttosubpoena.Such confidentiality shall be strictly maintained by the assistant secretary, all employees of the office, and by the academic institution and shall be used exclusively for the purpose of promulgating the workers' compensation reimbursement schedule.

WhoeverviolatesthisParagraphshallbeguiltyofamisdemeanorandfinednotmore than five hundred dollars for each offense.

(4) Notwithstanding anyother provisions ofthis Section, reimbursement for dentalservicesshallnotexceedtheseventiethpercentilein thecurrentedition ofthe NationalDentalAdvisoryService(NDAS)ComprehensiveFeeReport,utilizingthe average of geographic multipliers for Louisiana as published in the NDAS report.

* * * F.(1)Shouldadisputearisebetweenahealthcareproviderandtheemployee, employer, or workers' compensation insurer either payor regarding billing, payment, explanation of benefits, reconsideration, or the appropriate amount owedfortheprovisionofmedicalservicesthathavebeenrenderedpursuant to this Section,thedisputing partymayshall submit the dispute forresolution to the office in the same manner and subject to the same procedures as established for dispute resolution of claims for workers' compensation benefits of workers' compensation administration's medical services section in a form and manner as promulgated in rule by the assistant secretary.

The office shall render a decisionnolaterthanfifteenbusiness daysfromsubmissionofthedispute.The nonprevailing partyshall pay thecostof the review and if thejudgmentresults in the payment of a claim that was denied, interest shall be paid in the amount of twelve percent per annum from the date of the denial of the claim.

The Page 3 of 24 Coding:

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words in boldface type and underscored are additions.

SB NO.

408 ENROLLED decision of the office of workers' compensation administration's medical services section shall be final.

(2) Upon written notice of the decision by the workers' compensation administration's medical services section, the nonprevailing party may appeal the decision within thirty days of its receipt by certified mail.

The appeal shall be tothejudicialdistrictcourtof propervenueas provided in theCodeof Civil Procedure.

(3) The assistant secretary shall publish, at least annually, data and statistics regarding the disputes filed and the decisions rendered pursuant to this Section.

(4) In addition to any other occasion when consolidation of claims is otherwise allowed by applicable law, whenever Whenever multiple disputes exist between a single health care healthcare provider and a single "payor" as defined in R.S.

23:1142(A) concerning the proper amount payable pursuant to the reimbursementschedulethenworkers'compensation payor,eitherthehealth care healthcare provider or the payor shall have the right to have all such disputes between the payor and the health care healthcare provider consolidated and tried decided together.

The venue for such consolidated claims shall be in either the workers'compensation district of the parish in which the domicile of the provider is located or the workers' compensation district of the parish in which the domicile of the payor or employer is located.

(5) The assistant secretary shall promulgate rules and forms pursuant to the Administrative Procedure Act necessary to implement the dispute resolutionprocessprovidedforinthisSubsectionnolaterthanJanuary1,2028.

* * * §1201.

Time and place of payment;

failure to pay timely;

failure to authorize;

penalties and attorney fees * * * E.(1) Medical benefits payable under this Chapter shall be paid within sixty days after the employer or insurer receives written notice thereof, if the provider of Page 4 of 24 Coding:

Words which are struck through are deletions from existing law;

words in boldface type and underscored are additions.

SB NO.

408 ENROLLED medicalservicesis not utilizingthe electronicbillingrulesandregulations provided for in R.S.

23:1203.2.

(2) For those providers of medical services who utilize the electronic billing rules and regulations provided for in R.S.

23:1203.2, medical Medical benefits payable under pursuant to this Chapter shall be paid within thirty days after the employerpayor orinsurerreceivesacompleteelectronicmedicalbill,asdefinedby rules promulgated required by administrative rules promulgated by Louisiana Works.

(2) Failure to pay medical benefits as required by this Subsection shall be subject to fines and interest pursuant to R.S.

23:1121 shall result in the assessment of a penalty in an amount up to the greater of twelve percent of any unpaid compensation or medical benefits, or fifty dollars per calendar dayfor each dayin which anyand all compensation or medical benefitsremainunpaidorsuchconsentiswithheld,togetherwithreasonableattorney feesforeachdisputedclaim;however,thefiftydollarspercalendardaypenaltyshall not exceed a maximum of two thousand dollars in the aggregate for anyanyclaim. claim.

* * * (2)This(2) This Subsection shallnotshall applyiftheclaimisnot reasonablycontrovertedapply or if suchin nonpaymentany resultsof from conditions over which the employerfollowing orinstances: insurer had no control.

* * * Page 52 of 247 Coding:CODING:

WordsWordsinstruckthroughtypearedeletionsfromexistinglaw;wordsunderscored which are struckadditions. through are deletions from existing law;

wordsHCASB408 in4145 boldface5502 type(a) andIfthetheclaimis underscoredreasonablycontrovertedorifsuchnonpaymentresults arefrom additions.conditions over which the employer or insurer had no control.

SB(b) NO.If the claim is subject to the dispute resolution process provided in R.S.

40823:1034.2(F). ENROLLED §1203.

Duty* to* furnish*" medicalAMENDMENT andNO. vocational rehabilitation expenses;

prosthetic15 devices;On page 9, line 15, after "chiropractic" and before "of" change "therapy" to "treatment" AMENDMENT NO.

other16 expensesOn *page *10, *between B.lines 7 and 8 insert the following:

The"Section obligation2. of the employer to furnish such care, services, treatment, drugs, and supplies, whether in state or out of state, is limited to the reimbursement determined to be the mean of the usual and customary charges for such care, services, treatment, drugs, and supplies, as determined under the reimbursement schedule annually published pursuant to R.S.

23:1034.2 or the actual charge made for the service, whichever is less.

Any out-of-state provider is also to be subject to theproceduresestablishedundertheofficeofworkers'compensationadministration utilization review rules.

* * * §1203.1.

Definitions;

medical treatment schedule;

medical advisorycouncil * * * J.(1) After a medical provider has submitted to the payor the request for authorization and the information required by the Louisiana Administrative Code, Title 40, Chapter 27, the payor shall notify the medical provider of their its action ontherequestwithinfivebusinessdaysofreceiptoftherequest.Ifanydisputearises after January 1, 2011, Any request for authorization of office visits, diagnostic testing,chiropractictreatmentoftwelveofficevisitsorless,orphysicaltherapy of twelve office visits or less is considered authorized and approved by the payor, if it has not been specifically denied within five business days.

Upon expiration of five business days of submission of a request for authorization of nonsurgical treatment, the healthcare provider that made the request may notify the director of the office of workers' compensation that no denial of authorization has occurred on a form promulgated by the office of workers' compensation, and within five business days of receipt of such notice the director of the office of workers' compensation shall issue an order directing that the requested treatment, procedure, or testing is authorized, if it is found that the medical provider properly submitted to the payor the request for Page 6 of 24 Coding:

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SB NO.

408 ENROLLED authorization along with the information required by Chapter 27 of Title 40 of theLouisianaAdministrativeCode.Ifthepayorhastimelydeniedauthorization and a dispute arises as to whether the recommended care, services, or treatment is in accordance with the medical treatment schedule, or whether a variance from the medical treatment schedule is reasonably required as contemplated in Subsection I ofthis Section,anyaggrievedpartyshall file,withinfifteencalendardays,anappeal withtheofficeofworkers'compensationadministrationmedicaldirectororassociate medical director on a form promulgated by the assistant secretary.

The medical directororassociatemedicaldirectorshallrenderadecisionassoonasispracticable, but in no event, not more than thirty calendar days from the date of filing.

* * * Section 2.

23:1201.1(A), (B), (D), (E), (G) through (I), (J)(2) through (4), the(K)(1)(introductory introductoryparagraph) paragraphand of(2) (K)(1)and (K)(2) through (5) are herebyamendedhereby amended and reenacted to read as follows:

(2)SendthenoticeoftheinitialindemnitypaymentrequiredbyParagraph(2) SendthenoticeoftheinitialindemnitypaymentrequiredbyParagraph (1) of this Subsection to the injured employeeemployeeonthesamedayasno on the same day as no later than threeten businessbusinessdaysafterthefirstpaymentofcompensationismadebythepayorafterthe days after the first payment of compensation is made by the payor after the payor has received notice of the claim from the employer.

(3) Send a copy of the notice of the initial payment of indemnity required by Paragraph (1) of this Subsection to the office within ten days from the on the Pagesame 7date ofthe 24originalnoticewas Coding:sent to the injured employee or byfacsimile to the injured employee's representative.

Words which are struck through are deletions from existing law;

words in boldface type and underscored are additions.

SB NO.

408 ENROLLED same date the original notice was sent to theinjuredemployee or byfacsimile to the injured employee's representative.

(4)Sendthe"NoticeofPayment,Modification,Suspension,Termination,or Controversion of Compensation and/or Medical Benefits" to the injured employee by certified mail, to the address at which the employee is receiving payments of compensation, on or before the effective date of a modification, suspension, termination, or controversion.

The form of the "Notice of Payment, Modification, Suspension, Termination, or Controversion of Compensation and/or Medical Benefits" shall be promulgated by the office Upon any modification, suspension, termination, or controversionofcompensationormedicalbenefitsforanyreason,includingbut notlimitedtoissuesofnotlimitedtoissuesofmedicalcausation,compensability medicalcausation,compensability oftheclaim,orissues arising out of R.S.

* * * D.(1)AnynoticerequiredtobesenttotheinjuredemployeepursuanttoD.(1) Any notice required to be sent to the injured employee pursuant to this Section shall be sent by certified mail or commercial carrier to the address atwhichtheemployeeisreceivingpaymentofindemnitybenefits,byelectronicat which the employee is receiving payment of indemnity benefits, by electronic mail to the employee's electronic mail address on file with the employer or payor or by hand delivery to the employee.

Page 83 of 247 Coding:CODING:

WordsWordsinstruckthroughtypearedeletionsfromexistinglaw;wordsunderscored which are struckadditions. through are deletions from existing law;

wordsHCASB408 in4145 boldface5502 type(2) For purposes of receiving notice required by this Section, the employee shall provide a mailing address and underscoredan areelectronic additions.mail address upon request from the employer or payor.

SB(3) NO.Iftheinjuredemployeeisrepresentedbyanattorney,thenoticeshallalso be provided sent to the employee's representative attorney by facsimile, certified mail,commercialcarrier,electronicmail,orhand delivery.

408Proofthatthenotice ENROLLEDwas (2)sent Forto purposesthe ofemployee's receivingrepresentative noticeby facsimile as required by this Section,Paragraph the employee shall providebe aprima mailingfacie addressevidence andof maycompliance alsowith provideSubsection anA electronicof mailthis addressSection. upon request from the employer or payor.

(3)Iftheinjuredemployeeisrepresentedbyanattorney,thenoticeshallalso be provided sent to the employee's representative attorney by facsimile, certified mail, commercial carrier,electronicmail, orhand delivery.Proofthatthenotice was sent to the employee's representative by facsimile as required by this Paragraph shall be prima facie evidence of compliance with Subsection A of this Section.

* * * G.(1) If the employer or the payor provides the benefit that the employee claims is due, including any arrearage, on the returned form or letter of amicable demand within seven ten business days of receipt of the employee's demand, the employerorpayorshallemployer notor besubjecttopayor anyclaimshallnot forbesubjectto anypenaltiesanyclaimforanypenaltiesor orattorneyfeesattorneyfees arising from the disputed payment, modification, suspension, termination, or controversion.

(2) If the employer or payor does not provide the benefit that the employee claims is due, the employee mayfile a disputed claim for benefit provided it is filed withintheprescriptiveperiodestablishedunderR.S.23:1209.Iftheprescriptiondate of the claim occurs within the seven-dayten-dayprescriptive waitingperiod period,established theunder employeeR.S. will be allowed to file a disputed claim without waiting the seven ten business days as provided in Paragraph (1) of this Subsection.

23:1209.

If the prescription date of the claim occurs within the seven-dayten-day waitingperiod, the employee will be allowed to file a disputed claim without waiting the seven ten business days as provided in Paragraph (1) of this Subsection.

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WordsThe whichemployer areor struckthe throughpayor arewho deletionswishes to have a preliminary determination hearing shall request the hearing in his answer to the disputed claim arising from existingthe law;notice of initial payment or any subsequent modification, suspension,termination,ornoticeofcontroversion.

wordsIncaseswhereadisputedclaim is already pending when an issue arises from a subsequent notice of payment, modification, suspension, termination, or controversion of benefits, such request shall be made in boldfacean typeamended andpleading underscoredfiled arewithin additions.fifteen ten business days of the expiration of the seven-day ten-day period set forth in Paragraph (G)(1) of this Section.

SBI.(1) NO.Preliminary determinations as provided for in this Section are favored under the law and an An employer or payor who has not complied with therequirementssetforthineitherSubsectionAthroughEofthisSectionorhasnot initially accepted the claim as compensable, subject to further investigation and subsequent controversion or Subsection B of this Section, and who has provided notice as required by Subsection D of this Section, shall not be entitled to a preliminary determinationAn employer or payor who is not entitled to a preliminary determination or who is so entitled but fails to request a preliminary determinationmaybesubjecttopenaltiesandattorneyfeespursuanttoR.S.23:1201 at a trial on the merits or hearing held pursuant to Paragraph (K)(8) of this Section.

408(2) ENROLLEDIf H.disputed by the parties, upon a rule to show cause held prior to the preliminarydetermination or anyhearingheld pursuant to this Section, the workers' compensation judge shall determine whether the employer is in compliance An employee who objects to a request for a preliminary determination shall file a motion to strike the request within ten business days of receiving the documentation required to be produced by the employer or payor pursuant to Paragraph J(4) of this Section.

The employermotion or the payor who wishes to have a preliminary determination hearing shall requeststate the hearingfactual inand hislegal answerbases tofor the disputedobjection, claimand arising from the notice of initial payment or any subsequent modification, suspension, termination, or notice ofcontroversion.Incaseswherea disputed claim is already pending when an issue arises from a subsequent notice of payment, modification, suspension, termination, or controversion of benefits, such request shall be madeconsidered inby an amended pleading filed within fifteen ten business days of the expirationworkers' ofcompensation thejudge seven-dayby ten-daya periodrule setto forthshow incause Paragraphprior (G)(1)to ofany thispreliminary Section.determination hearing.

I.(1)Page An4 Preliminary determinations as provided for in this Section are favored under the law and an employer or payor who has not complied with the requirements set forth in either Subsection A through E of this7 SectionCODING: or has not initially accepted the claim as compensable, subject to further investigation and subsequent controversion or Subsection B of this Section, and who has provided notice as required by Subsection D of this Section, shall not be entitled to a preliminarydetermination.Anemployerorpayorwhoisnotentitledtoapreliminary determination or who is so entitled but fails to request a preliminary determination may be subject to penalties and attorney fees pursuant to R.S.

23:1201Wordsinstruckthroughtypearedeletionsfromexistinglaw;wordsunderscored atare aadditions. trial on the merits or hearing held pursuant to Paragraph (K)(8) of this Section.

(2)HCASB408 If4145 disputed5502 byFailure the parties, upon a rule to showfile cause held prior to the preliminarydeterminationmotion or anyhearing held pursuant to thisstrike Section,within the workers'prescribed compensationtime judgeperiod shall determinebe whetherdeemed the employer is in compliance An employee who objects to a requestwaiver for a preliminary determination shall file a notice of any objection to the requestpreliminary withindetermination twenty-onehearing. business days of receiving thedocumentationrequiredtobeproducedbytheemployerorpayorpursuant to Paragraph (J)(4) of this Section.

The notice of objection shall be considered by the workers’ compensation judge by a rule to show cause prior to any preliminarydeterminationhearing.Failuretofilethenoticeofobjectionwithin the prescribed time period shall be deemed a waiver of any objection to the preliminary determination hearing.Theassistant secretaryshall promulgate a Page 10 of 24 Coding:

Words which are struck through are deletions from existing law;

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SB NO.

408 ENROLLED standard notice of objection form in accordance with the Administrative Procedure Act.

* * * (2) The testimony of physicians may be introduced by certified records or deposition.Thepartiesmayagreetoallowuncertifiedmedicalrecordsandphysiciandeposition.The parties may agree to allow uncertified medical records and physician reports to be introduced into evidence.

(3) The preliminarypreliminarydetermination determination hearing shall be held no later than ninety days from the schedulingschedulingconference. conference.However, upon a showing of good cause, one extension of an additional thirty days is permitted upon approval by the workers' compensation judge.

However,uponashowingofgoodcause,one extension of an additional thirty days is permitted upon approval by the workers' compensation judge.

(4) Any employer or payor requesting a preliminary determination hearing shall produce all documentation relied on by the employer or payor in calculating, modifying,suspending,terminating,orcontrovertingtheemployee'sbenefits.Thesemodifying,suspending,terminating,orcontrovertingtheemployee'sbenefits. documentsshallbedisclosedtotheemployeeortheemployee'srepresentativewithin ten business days of the request for the preliminarydetermination hearing.

These documentsshallbedisclosedtotheemployeeortheemployee'srepresentativewithin ten business days of the request for the preliminarydetermination hearing.

Page(4) 11Any ofemployer 24or Coding:payor who does not accept the workers' compensation judge's determination or fails to comply with the determination within ten calendar business days, may, at the trial on the merits, be subject to penalties and attorney fees pursuant to R.S.

Words which are struck through are deletions from existing law;

words in boldface type and underscored are additions.

SB NO.

408 ENROLLED (4) Any employer or payor who does not accept the workers' compensation judge's determination or fails to comply with the determination within ten calendar business days, may, at the trial on the merits, be subject to penalties and attorney fees pursuant to R.S.

(5) AnyinjuredemployeewhoAnyinjuredemployeewhodisagreeswiththepreliminarydetermination disagrees with the preliminarydetermination shall notify the court within ten business days of the receipt of such preliminary determinationofhis desireto proceedtoatrialonthemeritsofthemattersthatproceedtoatrialonthemeritsofthemattersthatwere were the subject of the preliminary hearing.

23:1203.223:1208(A) is hereby amended and reenacted andto Subpartread Kas offollows: Part 1 of Chapter 10 of Title 23 of the Louisiana Revised Statutes of 1950, comprised of R.S.

23:1200.18.1§1208. through 1200.18.9, is hereby enacted to read as follows:

SUBPARTMisrepresentations K.concerning benefit payments;

ALLpenalty WORKERS'A.(1) COMPENSATIONIt MEDICALshall BILLbe DATABASEunlawful §1200.18.1.for any person, for the purpose of obtaining or defeating anybenefit or payment under pursuant to the provisions of this Chapter, either for himself or for any other person, to willfully make a false statement or representation.

ShortThe titleelementsrequiredforfraud Thisprovided Subpartforin shallthis beParagraph knownare exclusive and mayno befurther citedrequirements asare thenecessary "Louisianato Allestablish Workers'fraud Compensationpursuant Medicalto Billthis DatabaseSection. Act".

§1200.18.2.(2) Evidence that a false statement or representation does not alter a medical expert's opinion concerning causation or treatment of an injury or occupational disease compensable pursuant to this Chapter shall not be considered in defense to fraud as provided for in this Section, if the false Page 5 of 7 CODING:

TermsWordsinstruckthroughtypearedeletionsfromexistinglaw;wordsunderscored definedare Asadditions. used in this Subpart, unless the context clearly indicates otherwise, the following terms have the meanings ascribed to them:

(1)HCASB408 "Database"4145 means5502 thestatement Allor Workers'representation Compensationwould Medicalbe Billotherwise Database.prohibited pursuant to Paragraph (1) of this Subsection.

(2)"Medicalclaim"meansanyclaimsubmittedbyahealthcareprovider* to* a* payorSection for4. payment for healthcare services, pharmaceuticals, durable medicalequipment,orrelatedservicesprovidedtoanemployeepursuanttothis Page 12 of 24 Coding:

Words which are struck through are deletions from existing law;

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SB NO.

408 ENROLLED Chapter.

§1200.18.3.

Establishment of database A.(1) The assistant secretary of the office of workers' compensation administration shall establish and maintain the All Workers' Compensation Medical Bill Database.

(2)Thedatabaseshallcontainmedicalandpharmacyclaimsinformation submittedbyallpayorsprovidingworkers'compensationcoverageinthisstate.

B.

The purpose of the database shall be to do all of the following:

(1) Improve transparency in medical reimbursement trends.

(2) Assist in enforcement and maintenance of an appropriate fee schedule.

(3) Evaluate medical utilization patterns and outcomes.

(4) Detect fraud, waste, and abuse.

(5) Support policy development, rate analysis, and system oversight.

C.

The assistant secretary may retain and consult with qualified individualsororganizationswithexpertiseindataanalyticsandmedicalbilling forpurposesofcreation,operation,andmaintenanceofthedatabase.However, datacontainedinthedatabaseshallonlyconsistofclaimsdataobtaineddirectly from workers' compensation payors in this state.

D.(1) The office may retain, at its expense, a qualified and independent provider-based claims administrator or claims examiner with demonstrated expertise in Louisiana claims administration, reimbursement methodologies, and payor payment data analysis.

The administrator or examiner shall collect, analyze,andreportprofessionalandtechnicalclaimschargeandpaymentdata for actuarial review and system oversight purposes.

The submitted data shall beutilizedtodevelopevidence-basedfeeschedulerecommendationstotheoffice and to identify system imbalances, including:

(a) Outlier provider claims patterns.

(b) Unpaid claims.

(c) Underpaid claims.

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SB NO.

408 ENROLLED (d) Untimely paid claims.

(e) Revenue cycle management aging metrics by payor and by claim service line.

(2) The office shall utilize the data to promote transparency, accountability,and evidence-basedoperational practiceswithin thehealthcare claims payment system.

The office may evaluate provider claims activity and payor revenue cycle management behavioral algorithms to identify inefficiencies,improvedigitalandelectronicclaimsprocessingwork-flows,and enhance administrative efficiency throughout the system.

(3) All data collected and maintained pursuant to this Section shall remain confidential and shall be protected in accordance with applicable state andfederalprivacyanddatasecuritylaws.Theofficeshallestablishsafeguards necessary to preserve data integrity, prevent unauthorized disclosure, and ensure compliance with all applicable confidentiality requirements.

(4) The office may further utilize RCM data and actuarial findings to determinewhetherpenalties,correctiveactions,orotherenforcementmeasures should be assessed against providers for improper billing practices or against payors for improper payment practices, including patterns of delayed, denied, or inaccurate reimbursement.

§1200.18.4.

Mandatory reporting requirements A.(1)BeginningJanuary1,2027,allworkers'compensationpayorsshall submit to the assistant secretary of the office of workers' compensation administration medical and pharmacy claims data for all workers' compensation claims arising pursuant to state law.

(2) Submission shall occur in a format, time, and manner prescribed by rule of the office of workers' compensation administration.

B.

Required data elements shall include all of the following:

(1) Date of injury.

(2) Employer industry classification.

(3) Provider specialty and identifier.

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SB NO.

408 ENROLLED (4) Current procedural terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes, National Drug Code (NDC) codes, and International Classification of Diseases (ICD) codes, as applicable.

(5) Billed charge and allowed amount.

(6) Paid amount.

(7) Service dates.

(8) Utilization review actions.

(9) Claim status indicators.

C.

Data shall be submitted quarterly unless otherwise required by provisions of Part I of Title 40 of the Louisiana Administrative Code that establish, promulgate, and update the reimbursement schedule.

§1200.18.5.

Rulemaking authority A.

The assistant secretary of the office of workers' compensation administration shall promulgate rules in accordance with the Administrative Procedure Act to implement this Subpart.

B.

Rules shall include but not be limited to all of the following:

(1) Technical data submission standards.

(2) Data validation procedures.

(3) Compliance time lines.

(4) Procedures for correction of erroneous submissions.

(5) Standards for public reporting.

§1200.18.6.

Confidentiality and data protection A.(1)AllinformationcollectedpursuanttothisSubpartandmaintained in the database shall be confidential and privileged and shall not be public recordandsubjecttosubpoena.Thisconfidentialityshallbestrictlymaintained by the assistant secretary, all employees of the office, and by any agent or contractor of the state and shall be used exclusively for the purposes set forth in this Subpart.

Whoever violates the provisions of this Paragraph shall be guilty of a misdemeanor and fined not morethan five hundred dollars for each offense.

Page 15 of 24 Coding:

Words which are struck through are deletions from existing law;

words in boldface type and underscored are additions.

SB NO.

408 ENROLLED (2) The database shall comply with applicable state and federal privacy and security laws.

B.

Public reports shall present only aggregated or de-identified data.

§1200.18.7.

Authorized uses The assistant secretary of the office of workers' compensation administrationshallonlyusethedatabasedataforanyofthefollowingreasons:

(1) Monitoring compliance with medical fee schedule regulations.

(2) Studying medical cost drivers and utilization trends.

(3) Supporting actuarial review and rate analysis.

(4) Evaluating the effectiveness of medical treatment guidelines.

(5) Developing, revising, or modernizing the workers' compensation medical fee schedule pursuant to the provisions of this Subpart.

(6) Reporting annually to the legislature.

§1200.18.8.

Data integrity A.

The assistant secretary shall have the authority to investigate and audit the claim data submissions of any workers' compensation payor upon a reasonable belief that a payor or healthcare provider is engaging in conduct that may undermine the accuracy, completeness, or reliability of the data contained in the database.

B.

Each workers' compensation payor shall fully cooperate with any investigation or audit conducted pursuant to this Section and shall provide accesstoallrecords,documents,andinformationreasonablynecessarytoverify the accuracy and completeness of submitted data.

C.

Failure of a workers' compensation payor to fully cooperate with an investigation or audit conducted pursuant to this Section shall be grounds for theimpositionofacivilfine not toexceedtenthousand dollars perdayforeach day of noncompliance until such time as the payor fully complies with the requests of the assistant secretary.

§1200.18.9.

Penalties A.

If a payor fails to submit required data to the database on a timely Page 16 of 24 Coding:

Words which are struck through are deletions from existing law;

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SB NO.

408 ENROLLED basis, fails to correct submissions rejectedbecause of errors, or otherwise does not comply with the provisions of this Subpart or the rules and regulations promulgated tocarryout theprovisionsofthisSubpart,theassistant secretary shall provide written notice to the payor.

The assistant secretarymay grant an extension of time for justcause.Theassistant secretarymay assess a fine not to exceedfivehundreddollarsperdayfornoncomplianceafterwrittennoticeand opportunity to cure the noncompliance.

In determining whether to impose a penalty, the assistant secretary may consider mitigating factors, including the size and sophistication of a payor, the reasons for the failure to report, and the detrimental impact upon the public purpose served by the database.

B.

The assistant secretary may impose an additional administrative penalty of not more than ten thousand dollars per day for those violations the assistant secretary finds were willful.

In addition, any person who knowingly fails to comply with the confidentiality requirements of this Section or confidentiality rules adopted pursuant to this Section and uses, sells, or transfers the data or information for commercial advantage, pecuniary gain, personal gain, or malicious harm shall be subject to an administrative penalty of not more than fifty thousand dollars per violation.

* * * §1203.2.

Electronic medical billing and payment;

prior authorization A.(1) Beginning July 1, 2027, all claims for medical services rendered shall be submitted to a workers' compensation payor in electronic format.

The assistant secretary shall adopt rules and regulations regarding the electronic submission, processing, and payment of workers' compensation- related medical bills, in accordance with the Administrative Procedure Act, R.S.

49:950 et seq.

"Electronic claim" means a claim submitted by a healthcare provider, or its agent to a workers' compensation payor in an 837 (ASC X12N 837) format or its successor, adopted by the United States Department of Health and Human Services, or its successor, in compliance with the provisions of the Health Insurance Portability and Accountability Act (42 U.S.C.

1302d et seq., and 45 Page 17 of 24 Coding:

Words which are struck through are deletions from existing law;

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SB NO.

408 ENROLLED CFR Parts 160 and 162), that includes all of the following:

(a) Data that is required according to the United States Department of Health and Human Services standards for electronic transactions.

(b) Data that becomes required due to the situation according to the United States Department of Health and Human Services standards for electronic transactions.

(2)(a) Such rules shall takeeffectno later than January1, 2012.

Within five business days of receipt of an electronic claim, a workers' compensation payor or its agent shall review the entire claim and, if the workers' compensation payor determines that the claim is not an accepted claim, issue an exception report to the provider or its agent indicating all defects or reasons known at that time that the claim is not an accepted claim.

A provider who submits a claim that is not an accepted claim shall be deemed to have timely submitted a claim for the payment of covered healthcare services if the health insurance issuer or its agent fails to notify the healthcare provider, or the healthcare clearinghouse from which the claim was received, of all defects or reasons known at that time that the claim is not an accepted claim as required by this Subsection.

(b)Theexceptionreportshallcontain,ataminimum,allofthefollowing information, if known at that time, for each claim submitted:

(i) Patient name.

(ii) Provider claim number, patient account number, or unique identification number.

(iii) Date of service.

(iv) Total billed charges.

(v) Exception report issuer's name.

(vi) The date upon which the exception report was generated.

B.

Thefollowinggroups shall make provisions for such an electronicclaims system:

Workers' compensation payors shall adopt appropriate handling procedures approved by the office for the acceptance of electronic claim Page 18 of 24 Coding:

Words which are struck through are deletions from existing law;

words in boldface type and underscored are additions.

SB NO.

408 ENROLLED submissions.

The procedures shall include but not be limited to all of the following:

(1) Insurance carriers shall accept medical bills electronically submitted by health care providers, in accordance with the rules promulgated.

A process for electronicallyrecordingthetimeanddateofactualreceiptof electronicclaims.

(2) Health care providers shall accept payment of medical claims submitted electronically by insurance carriers, in accordance with the rules promulgated.

A process for electronic review of transmitted claims that assures all electronic claims received are reviewed for determination of whether the claims are deemed accepted in accordance with Subsection A of this Section.

(3) A process for reporting all claims not accepted and all defects or reasons known at that time that the claims were not accepted or rejected.

C.

Onorafter January1,2012,theThe assistant secretarymaycreateand maintain a statewide electronic prior authorization portal for purposes of approving medical care in accordancewith R.S.

23:1142.The portalshall have the capability to track and document prior authorization requests, responses, and supporting medical documentation.

The assistant secretary may conduct pilot programs limited to specific geographic areas or specific workers' compensationpayorspriortoinitiatingandmaintainingtheportalforstatewide use by all workers' compensation payors.

The assistant secretary may adopt additional rules and regulations, in accordance with the Administrative Procedure Act,R.S.49:950etseq.,regardingthecreation,operation,andmaintenanceofan electronic exchange of medical claims information for purposes of approving medical care in accordance with R.S.

23:1142.

D.(1) Nothing shall prohibit the assistant secretary from promulgating and adoptingrulesandregulations,inaccordancewiththeAdministrativeProcedureAct, R.S.

49:950 et seq., regardingthe development and implementation of a centralized datawarehouseforthecollectionofmedicalbillingandpaymentdata.Nolaterthan January1,2031,theassistantsecretaryshalldevelopandimplementaWorkers' Compensation Medical Quality and Outcomes Program designed to measure, Page 19 of 24 Coding:

Words which are struck through are deletions from existing law;

words in boldface type and underscored are additions.

SB NO.

408 ENROLLED evaluate,andimprovethequalityandeffectivenessofmedicalcareprovidedto injured employees pursuant to this Chapter.

(2) The program shall complement the purposes of the workers' compensation system by maintaining measurable indicators of quality and outcomes, which may include but not be limited to any of the following:

(a) Time to return to work.

(b) Functional improvement measures.

(c) Duration of disability and medical treatment episodes.

(d) Utilization of evidence-based treatment guidelines.

(3) In order to support the program, the office may collect and analyze data from the database.

(4) The office may develop mechanisms to identify best practices that improve recovery and return-to-work outcomes.

(5) The office may adopt rules in accordance with the Administrative Procedure Act as necessary to implement the provisions of this Section.

Section 4.

44:4.1(B)(12)23:1021(introductory isparagraph), 1123, 1221(introductory paragraph), (1)(d), and (3)(d)(introductory paragraph) and (ii) are hereby amended and reenacted toand readR.S. as follows:

§4.1.23:1221(3)(a)(iii) is herebyenacted to read as follows:

Exceptions§1021. * * * B.Thelegislaturefurtherrecognizesthatthereexistexceptions,exemptions, and limitations to the laws pertaining to public records throughout the revised statutesandcodesofthisstate.Therefore,thefollowingexceptions,exemptions,and limitations are hereby continued in effect by incorporation into this Chapter by citation:

*Terms *defined *As (12)used R.S.in this Chapter, unless the context clearly indicates otherwise, the following terms shall have be given the meaning meanings ascribed to them in this Section:

23:1177,* 1197,* 1200.7,* 1200.18.1,(16)(a) 1291,"Maximum 1292,Medical 1293,Improvement" 1306,or 1660,"MMI" 1671means *the *employee's *condition Sectionis 5.unlikely to improve substantially with or without medical treatment.

Beginning(b) noThe laterfact thanthat July 1, 2029, the assistantemployee secretaryofrequires theor officereceives of workers' compensation administration shall initiate formal rulemaking to update and modernize the workers'compensation medical feescheduletreatment usingtomaintain datahis derivedcondition fromortomanage thechronic Allpain Pageshall 20notpreventafinding of 24maximum Coding:medical improvement.

Words* which* are* struck§1123. through are deletions from existing law;

wordsDisputes inasto boldfacecondition typeorcapacityto work;additionalAdditional medical opinion regarding an examination under supervision of the assistant secretary If any dispute arises as to the condition of the employee, including but not limited to the cause of the condition, whether the employee is at maximum medical improvement, or the employee's capacity to work, the assistant secretary, upon application of any party, shall order an additional medical opinion regarding an examination of the employee to be made by a medical practitioner selected and underscoredappointed areby additions.the assistant secretaThe medical examiner shall report his conclusions from the examination to the assistant secretary and to the parties and such the report shall be prima facie evidence of the facts therein stated in any subsequent proceedings under pursuant to this Chapter.

SB* NO.* * §1221.

408Temporarytotaldisability;permanenttotaldisability;supplementalearnings ENROLLEDbenefits; Workers' Compensation Medical Claims Database established pursuant to this Act.

Thepermanent updatedpartial feedisability; schedule shall do all of the following:

(1)schedule Beof basedpayments onCompensation empiricalshall Louisiana-specificbe paymentpaid data.under pursuant to this Chapter in accordance with the following schedule of payments:

(2)(1) ProvideTemporary transparencyintotal. methodology, including statistical assumptions.

(3)* Promote* adequate* access(d) Anawardofbenefitsbasedontemporarytotaldisabilityshallceasewhen the physical condition of the employee has resolved itself to qualitycarethe forpoint injuredthat workers.a reasonablyreliable determination of the extent of disabilityof the employee maybe made and the employee's physical condition has improved to the point that continued, regular treatment by a physician is not required of maximum medical improvement (MMI).

(4)However, Supportin costno predictabilityevent andshall systembenefits stabilitybased foron employerstemporary andtotaldisability insurers.exceedamaximumoftwohundred eightweeks.

Themethodologyforpercentilecalculation,dataexclusions,geographicadjustments,Terminationof andtemporary statisticaltotal smoothingdisability shallbenefits bepursuant publishedto inthis detailParagraph andshall benot includedpreclude inan theaward notice of intentbenefits forpursuant rulemakingto forParagraphs public(2), review.(3), or (4) of this Section.

In* developing* the* inpatient(3) andSupplemental outpatientearnings hospitalbenefits. services and ambulatorysurgery services reimbursement amounts, the administrator shall do all of the following:

(1)(a) Analyze* allowed* amounts* and(iii) paidAn amountsemployee reflectedwho has exhausted eligibility for temporary total disability benefits pursuant to Subparagraph (1)(d) of this Section shall be entitled to supplemental earnings benefits in the database.manner provided in this Section.

(2)* Evaluate* reimbursement* percentiles(d) forThe comparableright servicesto acrosssupplemental geographicearnings regions.benefits pursuant to this Paragraph shall in no event exceed a maximum of five hundred twenty four hundred sixteen weeks, but shall terminate:

(3)Page Consider6 accessof to7 careCODING: metrics, including provider participation rates and treatment timeliness.

(4)Wordsinstruckthroughtypearedeletionsfromexistinglaw;wordsunderscored Revieware utilizationadditions. patterns and cost drivers by procedure category.

Themethodologyforpercentilecalculation,dataexclusions,geographicadjustments,HCASB408 and4145 statistical5502 smoothing* * * (ii) After receipt of a maximum of five hundred twenty four hundred sixteen weeks of benefits, provided that for anyweek during which the employee is paid any compensation under this Paragraph, the employer shall be publishedentitled into detaila andreduction beof includedone infull week of compensation against the noticemaximum number of intentweeks for rulemakingwhich forcompensation publicis review.payable under this Paragraph;

Nohowever, revisedfor feeany scheduleweek adoptedduring pursuantwhich tothe thisemployee Sectionis paid no supplemental earnings benefits, the employer shall becomenot effectivebe unlessentitled approvedto bythelegislatureandsignedbythegovernor.Theassistanta secretaryofreduction against the officemaximum number of workers'weeks compensationpayable administrationunder shallthis submit:Paragraph;

(1)or The* proposed* fee*" schedule.AMENDMENT NO.

(2)17 TheOn publishedpage methodology.10, line 8, change "Section 2." to "Section 5." AMENDMENT NO.

(3)18 TheOn actuarialpage impact17, analysis.line 17, change "Section 3." to "Section 6." AMENDMENT NO.

Not19 laterOn thanpage thirty17, daysdelete priorline to29 the start of the 2029 Regular Session of the Legislature,theassistantsecretaryshallsubmit awrittenreportto thelegislature.Thereport shall be submitted for the purpose of assisting the legislature in theits developmententirety and considerationinsert ofin futurelieu legislationthereof establishingthe orfollowing: revising a medical fee schedule or Page 21 of 24 Coding:

Words"Section which7. are struck through are deletions from existing law;

wordsR.S. in boldface type and underscored are additions.

SB23:1201.1(A)(4) NO.and (5) are herebyrepealed in their entirety.

408 ENROLLED reimbursement methodologyfor workers’ compensation medical services.

The report shall include, to the extent practicable and based upon data available to the office, an analysis of medical charges, allowed amounts, paid amounts, reimbursement patterns, utilization, provider access, and other factorsrelevantto the establishment of a workers’ compensation medical fee schedule.

The report shall include the following:

(1)Asummaryofcharge,allowedamount,andpaidamountdatabyprocedurecode, provider type, specialty, place of service, and geographic area.

(2) An analysis of median, average, and percentile-based reimbursement amounts, includingthetwenty-fifthpercentile,seventy-fifthpercentile,andninetiethpercentile,where sufficient data exists.

(3) A comparison of workers’ compensation reimbursement amounts to Medicare reimbursement amounts, including the percentage of Medicare paid by code, service category, provider type, specialty, and facility setting, where applicable.

(4) An analysis ofallowed-to-chargeratiosandvariations in billed charges, allowed amounts, and paid amounts.

(5) Identification of high-volume and high-cost services, including professional services,hospitaloutpatientservices,ambulatorysurgicalcenterservices,imaging,physical medicine, pain management, orthopedic services, and other categories determined relevant by the assistant secretary.

(6) An analysis of utilization patterns, including units of service, frequency of services, treatment intensity, and variation by injury type, provider type, specialty, and geographic area, where such information is available.

(7) An analysis of outlier billing, reimbursement, or utilization patterns, including unusualvariations,excessiveunits,upcoding,unbundling,duplicatebilling,orotherpatterns that may affect the reliability of fee schedule development.

(8) An analysis of provider access, including provider participation, appointment availability, geographic access, and any available information regarding delays in care, denial patterns, or treatment disputes.

(9) An analysis of total medical cost by claim or injury episode, including, where available,therelationshipbetweenreimbursement,utilization,disabilityduration,return-to- Page 22 of 24 Coding:

Words which are struck through are deletions from existing law;

words in boldface type and underscored are additions.

SB NO.

408 ENROLLED work outcomes, litigation, and claim closure.

(10) A discussion of potential reimbursement methodologies, including Medicare- based multipliers, percentile-based reimbursement, blended methodologies, geographic adjustments, service-category adjustments, or other approaches used in workers’ compensation medical fee schedules.

(11) Identification of data limitations, assumptions, exclusions, and areas where additional data may be necessary before a medical fee schedule or reimbursement methodology is proposed by legislation.

The report shall be informational onlyand shall not constitute a rule, regulation, fee schedule,reimbursementschedule,maximumallowablereimbursementamount,orproposed medical fee schedule.

Nothing in the report shall authorize the assistant secretary or the office to establish, implement, enforce, or require payment pursuant to a medical fee schedule unless expressly authorized by law.

Section 6.

The provisions of Section 1 of this Act shall only become effective upon approval by the legislature of the updated fee schedule as required in Section 5 of this Act.

Section 7.

The provisions of R.S.

23:1034.2(F) shall become effective no later than January 1, 2029.

TheBeginning provisionsno oflater thisthan SectionJune and30, Sections2029, 2, 3, 4, 5, 6, and 7 of this Act shall become effective upon signature by the governorassistant or,secretary if not signed by the governor, upon expiration of the timeoffice" forAMENDMENT billsNO. to become law without signature by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana.

If20 vetoedOn bypage the18, governordelete andlines subsequently24 approvedand by25 thein legislature,their thisentirety Actand shallinsert becomein effectivelieu onthereof the dayfollowing: following such approval.

Section9.Untiltheadoptionandpromulgationofarevisedreimbursementschedule"unless bytheapproved assistantby secretaryofthe Senate and House committees on labor and industrial relations and the officeSenate ofand workers’compensationHouse administrationcommittees pursuanton tohealth R.S.and welfare, meeting separately or jointly.

23:1034.2The andlegislature themay Administrativeapprove, Procedurereject, Act,or thereturn" currentAMENDMENT reimbursementNO. fee schedule and all rules, regulations, manuals, and reimbursement methodologies in effect prior to the effective date of this Act shall continue to govern reimbursement for medical services rendered under the Louisiana Workers’ Compensation Act.

21 On page 19, delete lines 5 through 8 in theirentiretyandinsertin lieu thereofthe following:

Section 9.

The provisions of Sections 1 and 7 shall only become effective upon approval by the Senate and House committees on labor and industrial relations and the Senate and House committees on health and welfare, meeting separately or jointly, of the updated fee schedule as required in Section 8 of this Act.

IfThe aprovisions reimbursementof schedulethis forSection care,and services,Sections treatment,2, drugs,3, 4, 5, 6, 8, and 9 shall become" Page 237 of 247 Coding:CODING:

WordsWordsinstruckthroughtypearedeletionsfromexistinglaw;wordsunderscored which are struckadditions. through are deletions from existing law;

words in boldface type and underscored are additions.

SB NO.

408 ENROLLED supplies has not been adopted and implemented on or before July 1, 2029, the assistant secretary shall, in accordance with the Administrative Procedure Act, promulgate all rules andregulationsnecessarytoestablish,implement,administer,andenforceareimbursement scheduleforsuchcare,services,treatment,drugs,andsupplies.Thereimbursementschedule shall be based upon usual and customary charges derived from the All Workers' Compensation Medical Bill Database.

Section 11.

If any provision or item of this Act, or the application thereof, is held invalid, such invalidity shall not affect other provisions, items, or applications of the Act which can be given effectwithout the invalid provision, item, or application and to this end the provisions of this Act are herebydeclared severable.

PRESIDENT OF THE SENATE SPEAKER OF THE HOUSE OF REPRESENTATIVES GOVERNOR OF THE STATE OF LOUISIANA APPROVED:

Page 24 of 24 Coding:

Words which are struck through are deletions from existing law;

words in boldface type and underscored are additions.