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Regular Session, 2012
SENATE BILL NO. 367
BY SENATOR RISER
WORKERS' COMPENSATI ON. Provides for medical examinations in workers'
compensation cases. (8/1/12)
AN ACT1
To amend and reenact R.S. 23:1123, 1142(A) and (B)(1), 1203(E), 1307, and 1317.1(A),2
relative to workers' compensation; to provide relative to independent medical3
examinations; to provide that certain information be given to certain injured workers;4
to provide relative to utilization review companies; and to provide for related5
matters.6
Be it enacted by the Legislature of Louisiana:7
Section 1. R.S. 23:1123, 1142(A) and (B)(1), 1203(E), 1307, and 1317.1(A) are8
hereby amended and reenacted to read as follows: 9
§1123. Disputes as to condition or capacity to work, or current medical treatment10
of employee; examination under supervision of the director11
If any dispute arises as to the condition of the employee , or the employee's12
capacity to work, or the current medical treatment for the employee, the director,13
upon application of any party, shall order an examination of the employee to be14
made by a medical practitioner selected and appointed by the director. The medical15
examiner shall report his conclusions from the examination to the director and to the16
parties and such report shall be prima facie evidence of the facts therein stated in any17 SB NO. 367
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subsequent proceedings under this Chapter.1
* * *2
§1142. Approval of health care providers; fees3
A. Definitions. For the purposes of this Section, the following terms shall4
have the following meanings unless the context clearly indicates otherwise:5
(1) "Payor" shall mean the entity responsible, whether by law or contract, for6
the payment of the medical expenses incurred by a claimant as a result of a work7
related injury.8
(2) "Utilization review company" shall mean the company or entity9
which contracts with the payor, and which entity reviews the claimant's medical10
records and information and makes the determination of medical necessity in11
accordance with this Chapter, for the purposes of assisting the payor with the12
authorization of the claimant's medical care, services and treatment requested13
pursuant to this Chapter.14
B. Nonemergency care. (1) (a) Except as provided herein, each health care15
provider may not incur more than a total of seven hundred fifty dollars in16
nonemergency diagnostic testing or treatment without the mutual consent of the17
payor and the employee as provided by regulation. Except as provided herein, that18
portion of the fees for nonemergency services of each health care provider in excess19
of seven hundred fifty dollars shall not be an enforceable obligation against the20
employee or the employer or the employer's workers' compensation insurer unless21
the employee and the payor have agreed upon the diagnostic testing or treatment by22
the health care provider.23
(b)(i) The payor may contract with a utilization review company to assist24
the payor in determining if the request for nonemergency diagnostic testing or25
treatment, in an amount which exceeds seven hundred fifty dollars, is a medical26
necessity as provided pursuant to this Chapter.27
(ii) A medical necessity determination by a utilization review company28
and the payor's consent to authorize the requested nonemergency diagnostic29 SB NO. 367
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testing and treatment shall only require a review of the claimant's medical1
records and shall not require an examination of the employee.2
* * *3
§1203. Duty to furnish medical and vocational rehabilitation expenses; prosthetic4
devices; other expenses5
* * *6
E. Upon the first payment for a claimant's medical care, service, or7
treatment, the payor, as defined in R.S. 23:1142(A)(1), shall communicate to the8
claimant information, in plain language, regarding the procedure for requesting an9
independent medical examination in the event a dispute arises as to the condition of10
the employee or the employee's capacity to work, and the procedure for11
appealing the denial of medical treatment to the medical director as provided12
in R.S. 23:1203.1. A payor shall not deny medical care, service, or treatment to a13
claimant unless the payor can document a reasonable and diligent effort in14
communicating such information. A payor who denies medical care, service, or15
treatment without making such an effort may be fined an amount not to exceed five16
hundred dollars or the cost of the medical care, service, or treatment, whichever is17
more.18
* * *19
§1307. Information to injured employee20
Upon receipt of notice of injury from the employer or other indication of an21
injury reportable under R.S. 23:1306, the office shall mail immediately to the injured22
employee and employer a brochure which sets forth in clear understandable language23
a summary statement of the rights, benefits, and obligations of employers and24
employees under this Chapter, together with an explanation of the operations of the25
office, and shall invite the employer and employee to seek the advice of the office26
with reference to any question or dispute which the employee has concerning the27
injury. Such brochure shall specifically state the procedure for requesting an28
independent medical examination in the event a dispute arises as to the condition of29 SB NO. 367
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the employee or the employee's capacity to work. If such brochure has previously1
been mailed to an employer within the calendar year, the office shall not mail such2
employer an additional brochure unless the employer specifically requests such.3
* * *4
§1317.1. Independent medical examinations5
A. Any party wishing to request an independent medical examination of the6
claimant pursuant to R.S. 23:1123, and 1124.1, and 1291(B)(10) and (11) shall be7
required to make its request at or prior to the pretrial conference. Requests for8
independent medical examinations made after that time shall be denied except for9
good cause or if it is found to be in the best interest of justice to order such10
examination.11
* * *12
The original instrument and the following digest, which constitutes no part
of the legislative instrument, were prepared by Carla S. Roberts.
DIGEST
Riser (SB 367)
Present law provides that, relative to workers' compensation, if any dispute arises as to the
condition of the employee, capacity to work, or the current medical treatment, the director
of the office of workers' compensation, upon application of any party, will order an
examination of the employee by a medical practitioner appointed by the director. Present law
further requires the medical examiner to report his conclusions from the examination to the
director and to the parties and provides such report shall be prima facie evidence of the facts
in any subsequent proceedings regarding the claimant's workers' compensation case.
Proposed law retains present law but eliminates current medical treatment as a basis for
dispute in this provision of present law.
Present law defines "payor" for purposes of workers' compensation as the entity responsible,
whether by law or contract, for the payment of the medical expenses incurred by a claimant
as a result of a work related injury.
Proposed law retains present law and adds the definition of "utilization review company" to
mean the company or entity which contracts with the payor and reviews the injured worker's
medical records and information and makes the determination of medical necessity, for the
purposes of assisting the payor with the authorization of the injured worker's medical care,
services and treatment.
Proposed law provides that the payor may contract with a utilization review company to
assist the payor in determining if the request for nonemergency diagnostic testing or
treatment, in an amount which exceeds $750, is a medical necessity.
Proposed law provides that a medical necessity determination by a utilization review
company and the payor's consent to authorize the requested nonemergency diagnostic testing SB NO. 367
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and treatment shall only require a review of the injured worker's medical records and shall
not require an examination of the injured employee.
Present law requires, in workers' compensation cases, the employer to furnish all necessary
drugs, supplies, hospital care and services, medical and surgical treatment, and any
nonmedical treatment recognized by the laws of this state as legal.
Present law requires that, upon the first payment for an injured worker's medical care,
service, or treatment, the payor, to communicate to the injured worker information regarding
the procedure for requesting an independent medical examination in the event a dispute
arises as to the condition of the employee. Present law further prohibits a payor from
denying medical care, service, or treatment unless the payor can document a reasonable and
diligent effort in communicating such information. Present law further provides that a payor
who denies medical care, service, or treatment without making such an effort may be fined
up to $500 or the cost of the medical care, service, or treatment, whichever is more.
Proposed law retains present law but provides that present law also applies to disputes about
the employee's capacity to work and the procedure for appealing the denial of medical
treatment to the medical director at the office of workers' compensation.
Present law requires that, upon receipt of notice of injury from the employer or other
indication of an injury, the office of workers' compensation administration shall mail
immediately to the injured employee and employer a brochure which sets forth in clear
understandable language a summary statement of the rights, benefits, and obligations of
employers and employees. Requires the brochure to specifically state the procedure for
requesting an independent medical examination in the event a dispute arises as to the
condition of the employee.
Proposed law retains present law but provides that present law also applies to disputes about
the employee's capacity to work.
Present law provides that the director of the office of workers' compensation shall have
certain powers, including the use of a utilization review process and to engage qualified
experts in the appropriate health-care fields to assist him in the discharge of his
responsibilities in utilization review.
Present law requires any party wishing to request an independent medical examination of
the claimant, including the examinations at the direction of the director of the office of
workers' compensation, to make its request at or prior to the pretrial conference.
Proposed law retains present law but removes the requirement that the request for an
independent medical examination made at the behest of the director shall be made prior to
the pretrial conference.
Effective August 1, 2012.
(Amends R.S. 23:1123, 1142(A) and (B)(1), 1203(E), 1307, and 1317.1(A))
Summary of Amendments Adopted by Senate
Committee Amendments Proposed by Senate Committee on Labor and Industrial
Relations to the original bill.
1. Add the definition of "utilization review company".
2. Authorizes payor to contract with a utilization review company to help
determine if nonemergency diagnostic testing or treatment in an amount over SB NO. 367
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$750 is a medical necessity.
3. Allows a medical necessity determination to be made by a utilization review
company where the company only reviews the injured worker's medical
records and does not administer a physical examination of the injured
worker.