HLS 12RS-1068 ORIGINAL
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Regular Session, 2012
HOUSE BILL NO. 959
BY REPRESENTATIVE LIGI
WORKERS COMPENSATI ON: Provides with respect to workers' compensation
AN ACT1
To amend and reenact R.S. 23:1123, 1124.1, 1201(F), 1210(A), 1221(3)(a) and (4)(s)(i), and2
1224 and to enact R.S. 23:1020.1, Subpart A-2 of Part II of Chapter 10 of Title 233
of the Louisiana Revised Statutes of 1950, to be comprised of R.S. 22:1213.14
through 1213.28, and R.S. 23:1314(D) and (E), relative to workers' compensation;5
to create the Louisiana Workers' Compensation Law; to provide with respect to6
medical treatment; to provide for medical provider networks; to provide for7
certification; to provide for benefits; to provide for medical services; to provide with8
respect to disabled workers; to provide for payment; to provide with respect to9
treating physicians; to provide for accessibility; to provide definitions; and to provide10
for related matters.11
Be it enacted by the Legislature of Louisiana:12
Section 1. R.S. 23:1123, 1124.1, 1201(F), 1210(A), 1221(3)(a) and (4)(s)(i), and13
1224 are hereby amended and reenacted and R.S. 23:1020.1, Subpart A-2 of Part II of14
Chapter 10 of Title 23 of the Louisiana Revised Statutes of 1950, comprised of R.S.15
23:1213.1 through 1213.28, and R.S. 23:1314(D) and (E) are hereby enacted to read as16
follows:17
§1020.1. Purpose; construction; evidentiary standard18
A. This Chapter shall be cited as the "Louisiana Workers’ Compensation19
Law".20 HLS 12RS-1068 ORIGINAL
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B. The purpose of workers’ compensation is to timely pay temporary and1
permanent disability benefits to any legitimately injured worker who has suffered an2
injury or developed a disease arising out of and in the course of his employment, to3
pay medical expenses that are due, and return the worker to the workforce at a4
reasonable cost to the employer. The Louisiana Workers’ Compensation Law is5
based on mutual renunciation of legal rights and defenses by employers and6
employees alike. It is the specific intent of the legislature that workers’ compensation7
cases shall be decided on the merits. The legislature hereby declares that disputes8
concerning the facts in workers’ compensation cases are not to be given a broad9
liberal construction in favor of either party, and that the laws pertaining to workers’10
compensation are to be construed in accordance with the basic principles of statutory11
construction. Furthermore, if the workers’ compensation statutes of this state must12
be changed, the legislature acknowledges the responsibility to do so. If the workers’13
compensation statutes are to be liberalized, broadened, or narrowed, such actions14
shall be the exclusive purview of the legislature.15
C. Unless otherwise provided in this Chapter, the evidentiary standard for the16
burden of proof shall be by a preponderance of the evidence and placed upon the17
party who is asserting entitlement to compensation, medical benefits, payment, or18
additional payment for services rendered to an employee. Preponderance of the19
evidence means evidence that, when weighed with that opposed to it, has more20
convincing force and the greater probability of truth. When weighing the evidence,21
the test is not the relative number of witnesses, but the relative convincing force of22
the evidence.23
* * *24
§1123. Disputes as to condition, capacity to work, or current medical treatment of25
employee; examination under supervision of the medical director26
If any dispute arises between the opinions of physicians as to the condition27
of the employee , or his capacity to work, or the current medical treatment for the28
employee, the medical director, upon application of any party or a workers'29 HLS 12RS-1068 ORIGINAL
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compensation judge, shall order an examination of the employee to be made by a1
medical practitioner selected and appointed by the medical director. The medical2
examiner shall be selected from any approved workers' compensation medical3
provider network. The medical examiner shall report his conclusions from the4
examination to the medical director and to the parties, who shall provide the report5
to the parties, and if applicable, to the requesting workers' compensation judge, and6
such report shall be prima facie evidence of the facts therein stated in any subsequent7
proceedings under this Chapter.8
* * *9
§1124.1. Cumulative medical testimony; medical examination10
Neither the claimant nor the respondent in hearing before the hearing officer11
shall be permitted to introduce the testimony of more than two physicians where the12
evidence of any additional physician would be cumulative testimony. However, the13
hearing officer, on his own motion, may order that any claimant appearing before it14
be examined by other physicians.15
* * *16
§1201. Time and place of payment; failure to pay timely; failure to authorize;17
penalties and attorney fees18
* * *19
F. Failure to provide payment in accordance with this Section or failure to20
consent to the employee's request to select a treating physician or change physicians21
when such consent is required by R.S. 23:1121 shall result in the assessment of a22
penalty in an amount up to the greater of twelve percent of any unpaid compensation23
or medical benefits, or fifty dollars per calendar day for each day in which any and24
all compensation or medical benefits remain unpaid or such consent is withheld,25
together with reasonable attorney fees for each disputed claim; however, the fifty26
dollars per calendar day penalty shall not exceed a maximum of two thousand dollars27
in the aggregate for any claim. The maximum amount of penalties which may be28
imposed at a hearing on the merits regardless of the number of penalties which might29 HLS 12RS-1068 ORIGINAL
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be imposed under this Section is eight thousand dollars. An award of penalties and1
attorney fees at any hearing on the merits shall be res judicata as to any and all2
claims for which penalties may be imposed under this Section which precedes the3
date of the hearing. Penalties shall be assessed in the following manner:4
(1) Such penalty and attorney fees shall be assessed against either the5
employer or the insurer, depending upon fault. No workers' compensation insurance6
policy shall provide that these sums shall be paid by the insurer if the workers'7
compensation judge determines that the penalty and attorney fees are to be paid by8
the employer rather than the insurer. In the event that the health care provider9
prevails on a claim for payment of his fee, penalties as provided in this Section and10
reasonable attorney fees based upon actual hours worked may be awarded and paid11
directly to him This Subsection shall not be construed to provide for recovery of12
more than one penalty or attorney fees.13
(2)(a) This Subsection shall not apply if the claim is reasonably controverted14
or if such nonpayment results from conditions over which the employer or insurer15
had no control unless the failure to make payment in accordance with this Section16
is arbitrary and capricious.17
(b) Such penalty and attorney fees shall be assessed against either the18
employer or the insurer, depending upon fault. No workers' compensation insurance19
policy shall provide that these sums shall be paid by the insurer if the workers'20
compensation judge determines that the penalty and attorney fees are to be paid by21
the employer rather than the insurer.22
(3) Except as provided in Paragraph (4) of this Subsection, any additional23
compensation paid by the employer or insurer pursuant to this Section shall be paid24
directly to the employee.25
(4) In the event that the health care provider prevails on a claim for payment26
of his fee, penalties as provided in this Section and reasonable attorney fees based27
upon actual hours worked may be awarded and paid directly to the health care28
provider. This Subsection shall not be construed to provide for recovery of more29 HLS 12RS-1068 ORIGINAL
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than one penalty or attorney fee. (a) For purposes of this Chapter, arbitrary and1
capricious shall mean conduct or behavior which is callous, willful, unreasoning, and2
egregious, and without consideration and regard for facts and circumstances3
presented. An action is not arbitrary and capricious when exercised honestly and4
upon due consideration, even though an erroneous conclusion has been reached. The5
reliance upon facts and circumstances, medical or vocational opinion, application of6
law, or any other information suggesting that a disputed benefit or claim might not7
be due shall preclude a finding of arbitrary and capricious conduct.8
(b) Attorney fees awarded under this Chapter shall be reasonable and only9
be paid based upon actual hours worked.10
(5) No amount paid as a penalty or attorney fee under this Subsection shall11
be included in any formula utilized to establish premium rates for workers'12
compensation insurance.13
* * *14
§1210. Burial expenses; duty to furnish15
A. In every case of death, the employer shall pay or cause to be paid, in16
addition to any other benefits allowable under the provisions of this Part, reasonable17
expenses of the burial of the employee, not to exceed seven eight thousand five18
hundred dollars.19
* * *20
SUBPART A-2. MEDICAL PROVIDER NETWORKS21
§1213.1 Existence or establishment of network; availability of treatment; approval22
and regulations23
A. (1) After January 1, 2013, any written contract or combination of written24
contracts that form the basis of a workers’ compensation medical provider network25
shall be governed by this Subpart.26
(2) The purpose of this Subpart is to provide standards to existing or newly27
created networks for medical services to injured employees by workers’28
compensation medical provider networks.29 HLS 12RS-1068 ORIGINAL
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§1213.2. Limitations on applicability1
This Subpart shall govern the creation, administration, evaluation, and2
enforcement of the delivery of medical services to injured employees by workers’3
compensation medical provider networks. The provisions of other statutes relating4
to the delivery of medical services to persons other than injured employees shall not5
apply unless specifically referenced in this Subpart. A workers’ compensation6
medical provider network shall not be subject to the provisions of Title 40 or Title7
22 of the Louisiana Revised Statutes. Any penalty, fine, or other monetary method8
allowed by law to prohibit or punish a certain act or failure to act, whether9
administrative, civil, or criminal, shall not apply to a workers’ compensation medical10
provider network unless expressly provided for in this Subpart.11
§1213.3. Definitions12
As used in this Subpart the following words, terms, and phrases have the13
meaning ascribed to them in this Section, unless the context clearly indicates a14
different meaning:15
(1) “Complainant” means a person who files a complaint pursuant to this16
Subpart, including an employee, an employer, a medical services provider, or17
another person designated to act on behalf of an employee.18
(2) “Complaint” means any written expression of dissatisfaction by a19
complainant to a network regarding any aspect of the network’s operation. The term20
includes dissatisfaction relating to medical fee disputes and network administration21
and the manner in which a service is provided. The term does not include a22
misunderstanding or a problem that is resolved promptly by clearing up the23
misunderstanding or supplying the appropriate information to the satisfaction of the24
complainant or a written expression of dissatisfaction with an adverse determination.25
(3) "Economic profiling" shall mean any evaluation of a particular physician,26
medical services provider, medical group or individual practice association based in27
whole or in part on the economic costs or utilization of services associated with28
medical care provided or authorized by the physician, medical services provider,29 HLS 12RS-1068 ORIGINAL
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medical group, or individual practice association.1
(4) “Emergency care” shall have the definition set forth in LAC 40:I, Chapter2
27, §2715.3
(5) “Fee dispute” means a dispute over the amount of payment due for4
medical services determined to be medically necessary and appropriate for treatment5
of a compensable injury.6
(6) “Medical services” means medical benefits owed to injured employees7
pursuant to R.S. 23:1203, including without limitation, medical care, services,8
treatment, drugs, supplies, translation, transportation, durable medical equipment,9
diagnostics, and any other medical related benefit provided to the injured employee10
pursuant to R.S. 23:1203 and 1203.1.11
(7) “Network” or “workers’ compensation medical provider network” means12
an organization that is in existence prior to the enactment of this Subpart and which13
becomes certified or formed as a workers’ compensation medical provider network.14
(8) "Office" means the office of workers' compensation administration.15
(9) “Payor” shall mean the entity responsible, whether by law or contract, for16
the payment of the medical expenses incurred by a claimant as a result of a work17
related injury.18
(10) “Person” means any individual, company, insurer, association,19
organization, reciprocal or inter-insurance exchange, partnership, business, trust,20
limited liability company, or corporation.21
(11) “Preauthorization” means the process required to request approval from22
the payor or the network to provide a specific treatment or service before the23
treatment or service is provided.24
(12) “Rural area” means an area that is not designated as an urbanized area25
by the United States Census Bureau.26
(13) “Service area” means a geographic area based upon the physical address27
of the employer’s business or the employee’s residence within which medical28
services from network providers are available and accessible to injured employees.29 HLS 12RS-1068 ORIGINAL
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(14) "Specialty contracting entity" means a for-profit or not-for-profit1
organization that contracts with medical services providers at a fixed contractual rate2
for the purpose of providing access to ancillary or complementary medical services,3
including but not limited to physical medicine, diagnostic radiology, durable medical4
equipment, home health care, and translation and transportation services, but not5
including treating physicians.6
§1213.4. Participation in network; notice of network requirements7
A. After January 1, 2013, a payor may establish a network to provide medical8
services, contract with another person for access to a network certified to provide9
medical services, maintain an existing network that was established by the payor, or10
that was contracted with the payor, provided that such network becomes certified,11
or choose not to participate in a network and continue to reimburse providers in12
accordance with R.S. 23:1034.2.13
B. An employer may have multiple specialty contracting entities, but only14
one certified workers' compensation medical provider services network within each15
service area.16
C. If a payor establishes, maintains, or contracts for access to a certified17
workers' compensation medical provider network, medical services owed to the18
injured employee shall be obtained only within the network or with a specialty19
contracting entity.20
D. (1) The injured employee shall be notified of the network requirements by21
the employer or by the payor. One notice is required, and the earliest notice22
provided shall be recognized as the date of the notice.23
(a) Written notice by the employer may occur prior to the accident and, if24
provided, shall be signed and dated by the employer on the date the notice is25
provided.26
(b) If the employee did not receive notice, or the injured employee's accident27
occurred prior to the network being certified or to the effective date of this Subpart,28
the payor shall provide notice to the injured employee. Verbal notice made directly29 HLS 12RS-1068 ORIGINAL
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to the injured employee shall constitute notice only if the payor mails a written1
notice within twenty-four hours. If verbal notice is not provided, the payor shall2
send written notice to the injured employee's address on record with the employer,3
and the date of the notice shall be the third day after it was mailed.4
(2) The written notice shall provide all of the following:5
(a) A statement to the employee that medical services shall be provided by6
a workers' compensation medical provider network.7
(b) The network's toll-free telephone number and address for obtaining8
additional information about the network, including information about network9
providers.10
(c) Contact information for the payor and the network.11
(d) A statement that in the event of an accident, the injured employee must12
select a treating physician from a list of all the network's treating physicians or a13
speciality contracting entity.14
(e) A statement that, except for emergency care, the injured employee shall15
obtain all medical services and any referrals for medical services, including16
specialists, through his treating physician.17
(f) An explanation that network providers have agreed to look only to the18
network or payor or speciality contracting entity, and not to injured employees for19
payment for medical services.20
(g) A statement that if the injured employee obtains medical services from21
a non-network provider, unless the provider is a speciality contracting entity, the22
payor shall not be liable, and the injured employee may be liable for payment for23
those medical services.24
(h) Information about how to obtain emergency care, including emergency25
care outside the service area, and after-hours care.26
(i) A list of the medical services for which the payor or network requires27
preauthorization or concurrent review.28
(j) An explanation regarding continuity of treatment in the event of the29 HLS 12RS-1068 ORIGINAL
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termination from the network of a treating physician.1
(k) A list of specialists that the network has chosen.2
(l) A website address that provides a list of network medical services3
providers within the appropriate service area updated at least quarterly, including the4
names and addresses of the medical services providers.5
(m) A description of the process by which a complainant shall initiate a6
complaint to the network.7
E. The network and the network's representatives and agents may not cause8
or knowingly permit the use or distribution to employees of information that is9
untrue or misleading.10
F. A network that contracts with a payor shall provide all the information11
necessary to allow the payor to comply with this Section.12
G. An injured employee is not required to comply with the network13
requirements until he has been given notice. Until such notice is provided, the payor14
shall be responsible for the cost of medical services.15
§1213.5. Payor responsibility for out-of-network medical services.16
A payor that provides medical services through a certified workers'17
compensation medical provider network shall be responsible for the following18
out-of-network care that is provided to an injured employee:19
(1) Emergency care.20
(2) Medical services provided to an injured employee when the network does21
not make available medical services providers necessary to treat the injured worker's22
specific condition within the accessibility standards.23
(3) Medical services provided by an out-of-network medical services24
provider pursuant to a referral from the injured employee's treating physician that is25
within the network, and such referral has been approved by the payor.26
§1213.6. Requirement to obtain network medical services27
An injured employee shall be required to obtain medical services through a28
certified workers' compensation medical provider network provided that the network29 HLS 12RS-1068 ORIGINAL
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meets the accessibility requirements.1
§1213.7. Certification required2
A. After January 1, 2013, no person shall operate a medical provider network3
or perform any function of a medical provider network unless he holds a certificate4
of authority.5
B. A workers' compensation medical provider network shall contract in6
writing with its medical services providers to provide for medical services. An entity7
certified as a workers' compensation medical provider network may have a written8
contract with a medical services provider accessed by more than one employer,9
provided that no employer has more than one network in each service area.10
§1213.8. Specialty contracting entity11
Specialty contracting entities may contract with certified networks and12
payors. Specialty contracting entities are not eligible for certification, but shall13
comply with the provisions of law relating to provider agreements.14
§1213.9. Certificate application 15
A. Any person may seek to operate a workers' compensation medical16
provider network.17
B. To operate a medical provider network, the applicant shall apply to the18
office of the workers' compensation administration for a certificate to organize and19
operate as a network.20
C. The application shall be filed, verified by the applicant or his21
representative, and accompanied by a non-refundable fee which shall be determined22
by rule.23
§1213.10. Contents of application24
Each application shall include all of the following:25
A. A cover page which shall include all of the following:26
(1) Type of applicant (payor, network contracting entity, or other entity).27
(2) Name of the applicant.28
(3) Applicant's tax identification number.29 HLS 12RS-1068 ORIGINAL
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(4) Name of medical provider network, if applicable.1
(5) Contact name, title, address, email address and telephone number of the2
person who will serve as the office's liaison.3
(6) Signed verification statement by an officer or employee of the applicant4
with the authority to act on behalf of the applicant with respect to the network. The5
verification shall state: "I, the undersigned officer or employee of the network6
applicant, have read and signed this application and know the contents thereof, and7
verify that, to the best of my knowledge and belief, the information included in this8
application is true and correct."9
B. A description of the applicant's service area or areas.10
C. A description of how the applicant complies with the accessibility11
standards.12
D. A sample of the employee notice.13
E. A description of the process by which a complainant may pursue a14
complaint with the network.15
§1213.11. Approval of certification; renewal16
A. The director shall approve or deny an application for certification no later17
than the sixtieth day after the date the completed application is received by the18
office. An application is considered complete on receipt of all of the required19
information. The director may request additional information that he may require20
to make the determination of approval.21
B. The director shall notify the applicant of any deficiencies in the22
application and may allow the applicant to request additional time to revise the23
application, in which case the sixty-day period for approval or denial is suspended.24
The director may grant or deny requests for additional time at the his discretion.25
C. An order issued by the director denying an application shall specify in26
which respects the application does not comply with applicable statutes and rules.27
An applicant whose application is denied may request a hearing under the Louisiana28
Administrative Procedure Act before the office. The request shall be made not later29 HLS 12RS-1068 ORIGINAL
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than the thirtieth day after the date of the director's denial order.1
D. The certification shall be valid until it is revoked or suspended. The2
licensee shall be under a duty to annually file any information needed to update his3
application. The office, by rule, may levy an annual fee to maintain the certificate.4
E. If the application meets the requirements for certification, the director may5
not withhold approval based on the selection of medical services providers. In6
developing a workers' compensation medical providers network, the payor or the7
contracted network shall have the exclusive right to determine the medical services8
providers in the network and to add or remove providers.9
§1213.12. Use of certain insurance terms by network prohibited10
A certified network whereby the payor is the applicant, whether created after11
or existing prior to the enactment of this Subpart, may identify the network as the12
payor's network. A network certified by an entity other than a payor, which then13
contracts with a payor, whether created after or existing prior to the enactment of this14
Subpart, may not identify the network as the payor's network but rather shall identify15
the network by name as the entity that was certified through application. 16
§1213.13. Restraint of trade; application of certain laws17
A. A network that contracts with a medical services provider or medical18
services providers practicing individually or as a group is not, because of the contract19
or arrangement, deemed to be in violation of any state law prohibiting arrangements20
or contracts which restrain trade.21
B. Notwithstanding any provision of the law to the contrary, a person who22
contracts with one or more medical services providers to conduct activities that are23
permitted by law but that do not require a certificate of authority, because of the24
contract, are deemed to be in violation of any law prohibiting arrangements or25
contracts which restrain trade.26
§1213.14. Treating physicians; referrals27
A. A network shall determine the specialty or specialties of physicians who28
may serve as treating physicians.29 HLS 12RS-1068 ORIGINAL
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B. For each compensable injury, an injured employee shall select a treating1
physician from the list of all treating physicians under contract with the network2
within the accessibility requirements.3
C. Each network shall, by contract, require treating physicians to provide, at4
a minimum, the functions and services for injured employees described by this5
Subpart.6
D. The treating physician shall provide medical services to the injured7
employee for the employee's compensable injury and shall make referrals to other8
network medical services providers where necessary, or make referrals to9
out-of-network medical services providers if medically necessary services are not10
available within the network accessibility requirements. Referrals to out-of-network11
providers shall be pre-approved by the payor.12
E. The treating physician shall participate in the medical case management13
and utilization review programs as required by the network, including participation14
in prompt return-to-work planning.15
§1213.15. Selection of treating physician16
A. An injured employee is entitled to his initial choice of a treating physician17
from the list provided by the network of all treating physicians under contract with18
the network who provide services within the applicable service area in which the19
injured employee lives. The following does not constitute an initial choice of treating20
physician:21
(1) A physician salaried by the employer.22
(2) A physician providing emergency care.23
(3) Any physician who provides care before the employee is required to24
obtain medical services from the network.25
B. An injured employee who is dissatisfied with the initial choice of a26
treating physician is entitled to select one alternate treating physician from the27
network's list of treating physicians who provides services within the applicable28
service area by notifying the payor in the manner prescribed by the network.29 HLS 12RS-1068 ORIGINAL
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C. An injured employee who is dissatisfied with the second treating physician1
shall obtain authorization from the payor to select any subsequent treating physician2
in the manner prescribed by the network. The network shall establish procedures and3
criteria to be used in authorizing an employee to select subsequent treating4
physicians. The criteria shall include, at a minimum, whether:5
(1) Treatment by the current treating physician is medically inappropriate.6
(2) The injured employee is receiving appropriate medical care to reach7
maximum medical improvement.8
(3) A conflict exists between the injured employee and the current treating9
physician to the extent that the physician-patient relationship is jeopardized or10
impaired.11
D. Denial of a request for any subsequent treating physician is subject to the12
appeal process for a complaint filed pursuant to this Subpart.13
E. A referral made by the treating physician, including a referral for a second14
or subsequent opinion or the selection of a treating physician because the original15
treating physician dies, retires, leaves the network, or a change of treating physician16
required because of a change of address by the employee to a location outside the17
accessibility requirements, does not constitute the selection of an alternate or any18
subsequent treating physician.19
§1213.16. Payment of medical services provider20
Notwithstanding any other provision of this Subpart, a payor shall pay,21
reduce, deny, or determine to audit, a claim for services provided through a workers'22
compensation medical provider network.23
§1213.17. Network contracts with providers24
A. A network shall enter into a written contract with each medical services25
provider, group of medical services providers, or a special contracting entity, that26
participates in the network. A medical services provider is confidential, is not27
subject to disclosure as public record information under R.S. 44:31, et seq, and is not28
subject to subpoena.29 HLS 12RS-1068 ORIGINAL
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B. Medical services provider contracts and subcontracts shall include all of1
the following provisions:2
(1) A hold-harmless clause stating that the network and the network's3
contracted medical services providers are prohibited from billing or attempting to4
collect any amounts from injured employees who are not responsible for payment,5
for medical services under any circumstances, including the insolvency of the payor6
or the network.7
(2) A clause regarding appeal by the medical services provider of8
termination of a medical services provider's contract and applicable written9
notification to injured employees regarding such a termination.10
C. Compensation to network medical services providers may not be11
structured to achieve the goal of reducing, delaying, or denying medical treatment12
or restricting access to medical treatment. Economic profiling is specifically13
authorized.14
§1213.18. Provider payment15
A. (1) The amount of payment for services provided by a network medical16
services provider is determined by the contract between the network and the medical17
services provider or group of medical services providers or between the special18
contracting entity and the medical services provider or group of medical services19
providers. The network and the medical services provider may agree to use any20
basis to calculate the payment including but not limited to the fee schedule21
established pursuant to R.S. 23:1034.2.22
(2) The contract between the network and the medical services provider or23
group of medical services providers may include provisions governing the following:24
(a.) The billing requirements for payment including the forms used to bill25
and a time frame for bill submission from date of service.26
(b.) The information required for submission of a bill to substantiate27
payment.28
(c.) The time frames and requirements to request reconsideration of a29 HLS 12RS-1068 ORIGINAL
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payment, reduced payment, or denial of payment.1
(d.) That the administrative review provisions of the contract must be2
exhausted prior to the filing of a disputed claim form LA-WC-1008.3
B. If a payor or network has preauthorized a medical service, the payor, or4
network, or the network's agent, or other representative may not deny payment to a5
medical services provider except for reasons other than medical necessity.6
C. Out-of-network providers, including providers located in and licensed to7
provide medical services in other states, who provide care as permitted by this8
Subpart, shall be paid as provided by the reimbursement schedule established9
pursuant to R.S. 23:1034.2 and applicable rules of the office, provided that nothing10
shall prohibit a network from negotiating payment for out-of-network services at a11
rate other than the reimbursement schedule established pursuant to R.S. 23:1034.2.12
D. Billing by, and payment to contracted and out-of-network medical services13
providers, shall be subject to the requirements of the Louisiana Workers'14
Compensation Law and applicable rules. Nothing in this Subpart shall be construed15
to require the application of rules of the office regarding reimbursement or payment,16
if application of those rules would change payment amounts negotiated by the17
network.18
E. A complainant may file a complaint with the network within sixty days19
after the occurrence of the incident that creates the basis of the complaint. After the20
receipt of a complaint timely filed, the network shall respond to the complaint in21
writing, either affirming, modifying, or reversing the problem set forth in the22
complaint within sixty days. The complainant shall not be entitled to further relief23
from the office of workers' compensation.24
§1213.19. Network-payor contracts25
A. A network may make available medical services to employees only26
pursuant to a written contract with a payor. A network-payor contract is confidential27
and is not subject to disclosure as public record information.28
B. A contract between the network and the payor shall include a clause which29 HLS 12RS-1068 ORIGINAL
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states that the role of the network is to make services available as agreed in the1
contract.2
§1213.20. Restrictions on payment and reimbursement3
A party to a payor-network contract may not sell, lease, or otherwise transfer4
information regarding the payment terms of the contract without the express5
authority of, and prior adequate notification to the other contracting parties.6
§1213.21. Network organization; service areas7
A. The network shall establish one or more service areas within this state.8
For each defined service area, the network shall demonstrate the ability to provide9
continuity, accessibility, availability, and quality of medical services to the10
satisfaction of the office.11
B. The network shall make a complete provider directory available to all12
employers with whom they contract in each service area, and to all injured13
employees of the employers. This directory may be made available through14
electronic means including but not limited to website access or electronic files.15
§1213.22. Accessibility and availability requirements16
A. All medical services shall be provided by a medical services provider who17
holds an appropriate license, unless the medical services provider is exempt from18
license requirements.19
B. A network's medical services provider panel shall include an adequate20
number of treating physicians and specialists, who shall be available and accessible21
to injured employees twenty-four hours a day, seven days a week. A network shall22
include sufficient healthcare providers to ensure choice, access, and quality of care23
to injured employees. The network shall have a minimum of two treating physicians24
and specialists qualified to treat the injuries most commonly experienced by injured25
employees.26
C. Hospital services shall be available and accessible twenty-four hours a27
day, seven days a week.28
D. Emergency care shall be available and accessible twenty-four hours a day,29 HLS 12RS-1068 ORIGINAL
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seven days a week, without restrictions as to where the services are rendered.1
E. Except for emergencies, a network shall make medical services, including2
the services of specialists, available injured employees on request.3
F. Each network shall ensure accessibility by providing that the distance from4
the employer's physical address or the employee's residence to a point of service by5
a treating physician or general hospital is not greater than thirty miles in non-rural6
areas and sixty miles in rural areas and that the distance from the employer's physical7
address or the employee's residence to a point of service by a specialist or specialty8
hospital is not greater than seventy-five miles in all areas.9
G. (1) The network shall submit an access plan to the office for approval at10
least thirty days before implementation of the plan if any medical service or network11
medical services provider is not available to an injured employee within the distance12
specified by Paragraph (F) of this Section.13
(2) Nothing shall prohibit a network from submitting, as part of its14
application, an access plan applicable to all its service areas allowing treatment with15
an out-of-network medical service provider in the event medical services are not16
available within the network mileage requirements established in Paragraph (F) of17
this Section.18
H. The network may make arrangements with medical services providers19
outside the service area to enable injured employees to receive a skill or specialty not20
available within the network service area.21
I. The network shall not be required to expand services outside the service22
area to accommodate injured employees who live outside the service area.23
§1213.23. Case management programs24
The network shall have the option of adopting a medical case management25
program to work with treating physicians, medical services providers, injured26
employees, and employers to facilitate cost-effective care and employee prompt27
return-to-work. Each network shall also have the option of adopting28
nationally-recognized return-to-work guidelines.29 HLS 12RS-1068 ORIGINAL
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§1213.24. Utilization review and retrospective review in network1
The requirements of R.S. 23:1142, 1203.1, and LAC 40:1, Chapter 27, shall2
apply to utilization review conducted in relation to claims in a workers'3
compensation medical provider services network. In the event of a conflict between4
R.S. 23:1142, 1203.1, and LAC 40:1, Chapter 27, and this Subpart, this Subpart shall5
control.6
§1213.25. Confidentiality requirements7
A. The office may access information from an executive agency that is8
otherwise confidential under any law of this state, including the Louisiana Workers'9
Compensation Law as necessary to implement the provisions of this Subpart.10
B. Confidential information provided to, or obtained by the office shall11
remain confidential and is not subject to disclosure under any public records law or12
be subject to subpoena under any other law. The office may not release any13
information that could reasonably be expected to reveal the identity of an injured14
employee or that discloses medical services provider discounts or differentials15
between payments and billed charges for individual medical services providers or16
networks.17
C. Information that is in the possession of the office and that relates to an18
individual injured employee, and any compilation, report, or analysis produced from19
the information that identifies an individual injured employe e, are not subject to20
discovery, subpoena, or other means of legal compulsion for release to any person21
or admissible in any civil, administrative, or criminal proceeding, except in22
connection with any claim for compensation pursuant to this Chapter.23
§1213.26. Determination of violation; notice24
A. If the director determines that a network, payor, or third party to which25
services have been delegated, is in violation of the provisions of the Louisiana26
Workers' Compensation Law or rules adopted pursuant thereto, the director or a27
designated representative may notify the network, payor, person, or third party of the28
alleged violation and may compel the production of any documents or other29 HLS 12RS-1068 ORIGINAL
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information as necessary to determine whether the violation occurred.1
B. The director may initiate the proceedings pursuant to this Section which2
shall be conducted in accordance with the Louisiana Administrative Procedure Act.3
C. If after a hearing, it is determined that a network, payor, or other person4
or third party has violated or is violating the Louisiana Workers' Compensation Law,5
or rules adopted pursuant thereto, the office may suspend or revoke his certificate,6
issue a cease and desist order, or both.7
§1213.27. Economic profiling8
A payor that offers a workers' compensation medical provider network and9
that uses economic profiling shall maintain a description of any policies and10
procedures related to economic profiling utilized by the network. The description11
shall describe how economic profiling is used in utilization review, peer review,12
incentive and penalty programs, and in medical services provider retention and13
termination decisions. The network shall, upon request, provide a copy of the filing14
to an individual physician, medical services provider, medical group, or individual15
practice association.16
§1213.28. Continuity of medical care; retention or termination of medical services17
providers18
A. A payor or employer that arranges for care for injured workers through a19
workers' compensation medical provider network shall develop and maintain a20
written continuity of care policy and maintain information regarding the process for21
an injured employee to request a review under the policy, and shall provide, upon22
request, a copy of the written policy to an employee.23
B. At the request of an injured employee who was receiving services from a24
medical services provider for one of the conditions described in this Section, a payor25
or employer who offers a workers' compensation medical provider network shall26
provide the completion of treatment at the time of the medical services provider27
contract's termination.28
C. The payor or employer shall provide for the completion of treatment for29 HLS 12RS-1068 ORIGINAL
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the following conditions subject to coverage:1
(1) An acute condition. An acute condition is a medical condition that2
involves a sudden onset of symptoms due to compensable injury or disease that3
requires prompt medical attention and that has a limited duration. Completion of4
treatment shall be provided for the duration of the acute condition.5
(2) A serious chronic condition. A serious chronic condition is a medical6
condition due to a compensable injury or disease that is serious in nature and that7
persists without full cure, or worsens over an extended period of time, or requires8
ongoing treatment to maintain remission or prevent deterioration. Completion of9
treatment shall be provided for a period of time necessary to complete a course of10
treatment and to arrange for a safe transfer to another medical services provider, as11
determined by the payor or employer in consultation with the injured employee and12
the terminated medical services provider, and consistent with good professional13
practice. Completion of treatment shall not exceed twelve months from the medical14
services provider contract termination date.15
(3) A terminal illness. A terminal illness is an incurable or irreversible16
condition as a result of a compensable injury or disease that has a high probability17
of causing death within one year or less. Completion of treatment shall be provided18
for the duration of a terminal illness.19
(4) Surgery. The performance of a surgery or other procedure that is20
authorized by the payor or employer and which is part of a documented course of21
treatment and which has been recommended and documented by the medical22
services provider to occur within one hundred-eighty days of the medical services23
provider contract's termination date.24
D. The payor or employer shall ensure that the requirements of this Section25
are met.26
E. The payor or employer is not required to provide for completion of27
treatment by a medical services provider whose medical services provider contract28
with the payor or employer has been terminated or not renewed for reasons related29 HLS 12RS-1068 ORIGINAL
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to a medical disciplinary cause or reason, fraud, or any criminal activity.1
F. Nothing in this Section shall prohibit a payor or employer from providing2
continuity of care beyond the requirements of this Section.3
* * *4
§1221. Temporary total disability; permanent total disability; supplemental earnings5
benefits; permanent partial disability; schedule of payments6
Compensation shall be paid under this Chapter in accordance with the7
following schedule of payments:8
* * *9
(3) Supplemental earnings benefits.10
(a) (i)For injury resulting in the employee's inability to earn wages equal to11
ninety percent or more of wages at time of injury, supplemental earnings benefits,12
payable monthly, equal to sixty-six and two-thirds percent of the difference between13
the average monthly wages at time of injury and average monthly wages earned or14
average monthly wages the employee is able to earn in any month thereafter in any15
employment or self-employment, whether or not the same or a similar occupation as16
that in which the employee was customarily engaged when injured and whether or17
not an occupation for which the employee at the time of the injury was particularly18
fitted by reason of education, training, and experience, such comparison to be made19
on a monthly basis. Average monthly wages shall be computed by multiplying his20
"wages" by fifty-two and then dividing the quotient by twelve.21
(ii) When the employee is no longer temporarily and totally disabled, but is22
not earning any income and the employer has not established earning capacity23
pursuant to R.S. 23:1226, payments of benefits shall continue in accordance with24
R.S. 23:1201(A)(1).25
* * *26
(4) Permanent partial disability. In the following cases, compensation shall27
be solely for anatomical loss of use or amputation and shall be as follows:28
* * *29 HLS 12RS-1068 ORIGINAL
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(s)(i) In addition to any other benefits to which an injured employee may be1
entitled under this Chapter, any employee suffering an injury as a result of an2
accident arising out of and in the course and scope of his employment shall be3
entitled to a sum of thirty fifty thousand dollars, payable within one year after the4
date of the injury. Interest on such payment shall not commence to accrue until after5
it becomes payable. Such payment shall not be subject to any offset for payment of6
any other benefit under this Chapter. Such payment shall not be subject to a claim7
for attorney fees; however, attorney fees may be awarded in a claim to collect such8
payment pursuant to R.S. 23:1201.2.9
* * *10
§1224. Payments not recoverable for first week; exceptions11
No compensation shall be paid for the first week after the injury is received;12
provided, that in cases where disability from injury continues for six two weeks or13
longer after date of the accident, compensation for the first week shall be paid after14
the first six two weeks have elapsed.15
* * *16
§1314. Necessary allegations; dismissal of premature petition17
* * *18
D. Notwithstanding any other provisions of this Section to the contrary, the19
employer shall be permitted to file a claim relative to any dispute arising under this20
Chapter or to controvert benefits.21
E. Disputes over whether medical treatment is due under the medical22
treatment schedule shall be premature unless a decision of the medical director has23
been obtained.24 HLS 12RS-1068 ORIGINAL
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DIGEST
The digest printed below was prepared by House Legislative Services. It constitutes no part
of the legislative instrument. The keyword, one-liner, abstract, and digest do not constitute
part of the law or proof or indicia of legislative intent. [R.S. 1:13(B) and 24:177(E)]
Ligi HB No. 959
Abstract: Creates the Louisiana Workers' Compensation Law.
Proposed law (R.S. 23:1020.1) provides that the purpose of workers' compensation is to
timely pay disability benefits to injured workers so that the workers can reenter the
workforce.
Proposed law requires that workers' compensation statutes are not to be construed in favor
of the employee or the employer and cases should be decided by a preponderance of the
evidence.
Present law (R.S. 23:1123) provides that if a dispute arises over the medical treatment of an
employee, the director shall order an examination by a medical practitioner selected by the
director, and that the medical practitioner shall report his conclusions to the director and to
the parties.
Proposed law changes present law to provide that if there is a dispute between physicians
as to the condition of the employee, the medical director shall order an examination of the
employee, upon application of any party or a workers' compensation judge, by a medical
practitioner selected by the medical director from the approved workers' compensation
medical network.
Proposed law provides that the medical examiner shall report his conclusions to the medical
director, who shall provide the report to the parties and the workers' compensation judge (if
applicable).
Present law (R.S. 23:1124.1) provides that neither the claimant or the respondent may
introduce the testimony of more than 2 physicians at a hearing unless the hearing officer
orders the claimant be examined by other physicians.
Proposed law deletes the option for the hearing officer to make a motion to have the claimant
examined by an additional physician.
Present law (R.S. 23:1201(F)) provides that failure to provide payment or to consent to the
employee's request to select a treating physician or change physicians shall result in a
penalty.
Present law provides that the penalty and attorney fees shall be assessed against the
employer or the insurer, depending on fault, and that no policy shall require that the insurer
pay the fines if the workers' compensation judge determines that the penalty and attorney
fees are instead to be paid by the employer.
Proposed law retains present law, but moves it to a different location within the same
Section.
Present law provides that when a health care provider prevails on a claim for payment of
fees, that these fees and attorney fees shall be paid directly to the health care provider.
Proposed law retains present law, but moves it to a different location within the same
Section. HLS 12RS-1068 ORIGINAL
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Present law provides that present law shall not apply if the nonpayment results from
conditions over which the employer or insurer had no control.
Proposed law deletes present law and provides that the provisions shall not apply unless the
failure to make a payment is arbitrary and capricious.
Proposed law provides that arbitrary and capricious shall mean conduct or behavior which
is callous, willful, unreasoning and egregious, and without consideration and regard for facts
and circumstances presented.
Proposed law provides that any attorney fees awarded shall be reasonable and based on
actual hours worked.
Present law (R.S. 23:1210) provides that in cases of death, an employer shall pay burial costs
up to $7,500.
Proposed law changes the amount of burial costs an employer may pay from $7,500 to
$8,500.
Proposed law (R.S. 23:1213.1) provides that proposed law is to govern the creation,
administration, evaluation, and enforcement of the delivery of medical services to injured
employees by workers' compensation medical provider networks.
Proposed law provides that it shall not be subject to provisions of the insurance code or the
public health and safety code.
Proposed law (R.S. 23:1213.2) provides for definitions of terms to be used in proposed law.
Proposed law (R.S. 23:1213.3) provides that a payor may establish a network to provide
medical services, contract with someone else to provide medical services, maintain an
existing network, or choose not to participate in a network.
Proposed law provides that an employer may only have one workers' compensation medical
provider services network within each service area, but multiple specialty contracting
entities.
Proposed law provides that if a payor establishes a network, the injured employee shall
obtain his medical services within the network.
Proposed law provides that if the employee did not receive notice, or if the accident occurred
before the network was certified, he shall be given notice by the payor.
Proposed law provides that the employee will be notified of the network in writing, by the
employer, and that this notification shall include contact information for the network, a list
of treating physicians, an explanation of continuity of treatment, a list of specialties that the
network has chosen, and other information about network providers.
Proposed law (R.S. 23:1213.4) provides that an employee is liable for costs for out-of-
network providers, except for emergency care, care that isn't provided by the network, an
out-of-network referral by the treating physician.
Proposed law (R.S. 23:1213.5) requires that an injured employee shall obtain medical
services through a certified workers' compensation medical provider network.
Proposed law (R.S. 23:1213.6, 1213.8, 1213.9) provides that a person must be certified to
operate a network, and provides that the certification can be obtained by the office of
workers' compensation administration, and outlines the procedure for doing so. HLS 12RS-1068 ORIGINAL
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are additions.
Proposed law (R.S. 23:1213.7) provides that special contracting entities are not eligible for
certification, but can contract with medical service providers at a fixed contractual rate to
provide medical services.
Proposed law (R.S. 23:1213.10) provides for the approval or disapproval of an application
for certification or a renewal.
Proposed law (R.S. 23:1213.11) prohibits a network from being identified as the payor's
network if the network is certified by an entity other than the payor.
Proposed law (R.S. 23:1213.13 et seq.) provides that the network shall determine the
specialty of physicians who may serve as treating physicians.
Proposed law provides that an injured employee shall selected a treating physician from the
list of treating physicians in the network, for each compensable injury and provides a list of
physicians that do not qualify as treating physicians.
Proposed law provides that the treating physician shall treat the injured employee, make
referrals when necessary, and participate in the medical case management and utilization
review programs as required by the network.
Proposed law provides that if an employee is dissatisfied with his treating physician, he is
entitled to an alternate physician from the network list, but if the employee is dissatisfied
with the 2
nd
treating physician, the network shall establish procedures in authorizing another
selection.
Proposed law (R.S. 23:1213.15) provides for the payment of a medical services provider by
a payor.
Proposed law (R.S. 23:1213.16) provides that a network shall enter into a contract with each
medical services provider or special contracting entity that participates in the network, and
outlines the clauses that shall be included in the contract.
Proposed law (R.S. 23:1213.17) provides that the amount of payment to a medical service
provider will included in the contract.
Proposed law (R.S. 23:1213.18 and 1213.19) provides that except for emergencies and out-
of-network referrals, a network may only make medical services available to employees
pursuant to a written contract with the payor, and that the parties may not sell, lease, or
otherwise transfer information regarding the terms of the contract..
Proposed law (R.S. 23:1213.20 and 1213.21) requires that the network establish services
areas within the state that provide a broad range of accessible services, physicians, and
hospitals, with hospital and emergency access 24 hours a day.
Proposed law provides that the network's plan for accessible service must be submitted to
the office at least 30 days before implementation.
Proposed law (R.S. 23:1213.23) provides that in the event of a conflict between present law
and proposed law, proposed law shall control.
Proposed law (R.S. 23:1213.24) requires confidentiality, and requires that information
obtained under the Workers' Compensation Law is not subject to subpoena, discovery, or
other means of legal compulsion for release to any person.
Proposed law (R.S. 23:1213.25) entitles the director to access to any documents from the
network, payor, or other person whom the director believes is in violation of proposed law. HLS 12RS-1068 ORIGINAL
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Proposed law provides that the director may initiate proceedings for violations and that any
proceedings are subject to the APA.
Proposed law provides that upon a finding of a violation, the office may suspend or revoke
any certificate issued by the office, issue a cease and desist order, or both.
Proposed law (R.S. 23:1213.26) provides that a payor who uses economic profiling shall
maintain a description of any policies and procedures related to the economic profiling and
provide a copy, upon request, to a physician, medical services provider, medical group, or
individual practice association.
Proposed law (R.S. 23:1213.27) provides that any payor or employer who arranges care
through a network shall develop and maintain a written continuity of care policy and provide
the policy to an employee upon request.
Proposed law further provides that the payor shall provide a completion of treatment by a
terminated medical services provider when requested to do so by the injured employee
unless the medical services provider whose services were terminated were terminated or not
renewed for reasons related to a medical disciplinary cause or for criminal activity.
Proposed law requires that the complement of treatment be provided for acute conditions,
serious chronic conditions, terminal illnesses, and surgeries.
Present law (R.S. 23:1221) provides for compensation for disabled employees.
Proposed law retains present law and further provides that when the employee is no longer
disabled, but is not earning any income, or the employer has not established earning
capacity, that benefit payments shall continue.
Present law provides that in addition to any other benefits to which an injured employee with
a permanent partial disability may be entitled, any employee suffering an injury as a result
of an accident arising from his employment shall be entitled to a sum of $30,000 within one
year of the date of the injury.
Proposed law changes the amount of money owed from $30,000 to $50,000.
Present law (R.S. 23:1224) provides that no compensation shall be paid the 1
st
week of an
injury, except in cases wherein the disability from the injury continues for 6 weeks or longer,
the 1
st
week compensation shall be paid after the 1
st
6 weeks have elapsed.
Proposed law changes the time periods from 6 weeks, to 2 weeks.
Present law (R.S. 23:1314) provides for the dismissal of a prematurely filed petition, and
provides that a workers' compensation judge shall determine whether a petition is premature
and must be dismissed.
Proposed law provides that an employer shall be permitted to file a claim concerning
disputes, and that disputes over whether medical treatment is due under the medical
treatment schedule shall be premature unless a decision of the medical director has been
obtained.
(Amends R.S. 23:1123, 1124.1, 1201(F), 1210(A), 1221(3)(a) and (4)(s)(i), and 1224; Adds
R.S. 23:1020.1, 1213.1-1213.28, and 1314(D) and (E))