HLS 14RS-1729 ORIGINAL
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are additions.
Regular Session, 2014
HOUSE BILL NO. 1190
BY REPRESENTATIVE GAINES
WORKERS COMPENSATI ON: Provides with respect to the medical treatment schedule
AN ACT1
To amend and reenact R.S. 23:1203.1(I), (J)(1), (K), and (M), relative to the workers'2
compensation medical treatment schedule; to provide with respect to the application3
and procedure for determining disputes; provides for the procedure and required time4
periods for the appeal of decisions by the medical director; and to provide for related5
matters.6
Be it enacted by the Legislature of Louisiana:7
Section 1. R.S. 23:1203.1(I), (J)(1), (K), and (M) are hereby amended and reenacted8
to read as follows:9
ยง1203.1. Definitions; medical treatment schedule; medical advisory council10
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I. After the promulgation of the medical treatment schedule, throughout this12
Chapter, and notwithstanding any provision of law to the contrary, medical care,13
services, and treatment due, pursuant to R.S. 23:1203, et seq., by the employer to the14
employee shall mean care, services, and treatment in accordance with the medical15
treatment schedule. The provisions of this Section shall not apply to any case in16
which the employee sustained an accident, injury, or occupational disease before17
July 13, 2011. Medical An employer is required to pay for medical care, services,18
and treatment that varies from the promulgated medical treatment schedule shall also19
be due by the employer when it is demonstrated to the medical director of the office20 HLS 14RS-1729 ORIGINAL
HB NO. 1190
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by a preponderance of the scientific medical evidence, that a variance from the1
medical treatment schedule is reasonably required to cure or relieve the injured2
worker from the effects of the injury or occupational disease given the3
circumstances.4
J.(1) After a medical provider has submitted to the payor the request for5
authorization and along with the information required by the Louisiana6
Administrative Code, Title 40, Chapter 27, the payor shall notify the medical7
provider of their his action on the request within five business days of receipt of the8
request. If any dispute arises after January 1, 2011, as to Any request for9
authorization is considered authorized and approved by the payor if it has not been10
specifically denied within five business days. If the payor disputes whether the11
recommended care, services, or treatment is in accordance with the medical12
treatment schedule, or whether a variance from the medical treatment schedule is13
reasonably required as contemplated in Subsection I of this Section, any aggrieved14
party the payor shall file, within fifteen calendar days, an appeal within fifteen15
calendar days with the office of workers' compensation administration medical16
director or associate medical director on a form promulgated by the director. The17
medical director or associate medical director shall render a decision as soon as is18
practicable, but in no event, not more than thirty calendar days from the date of19
filing.20
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K. After the issuance of the decision by the medical director or associate22
medical director of the office, any party who disagrees with the decision, may then23
appeal by filing a "Disputed Claim for Compensation", which is LWC Form 1008,24
within thirty days of the issuance of the decision. The decision may be overturned25
when it is shown, by clear and convincing evidence by a preponderance of the26
evidence that the decision of the medical director or associate medical director was27
not in accordance with the provisions of this Section. Any competent, relevant28
evidence shall be admissible at the hearing of the appeal. The party who files the29 HLS 14RS-1729 ORIGINAL
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appeal shall notify the director that he has done so within ten days. The director1
shall compile and forward the entire record used by the medical director in issuing2
the decision to the district hearing office within fifteen days of receiving notice. The3
record shall be made available to the parties to the appeal upon request.4
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M.(1) With regard to all treatment not covered by the medical treatment6
schedule promulgated in accordance with this Section, all medical care, services, and7
treatment shall be in accordance with Subsection D of this Section R.S. 23:1203.8
(2) Notwithstanding any other provision of this Chapter, all treatment not9
specified in the medical treatment schedule and not found in Subsection D of this10
Section shall be due by the employer when it is demonstrated to the medical director,11
in accordance with the principles of Subsection C of this Section, that a12
preponderance of the scientific medical evidence supports approval of the treatment13
that is not covered.14
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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)]
Gaines HB No. 1190
Abstract: Provides for the procedure for determining disputes and appeals of the medical
director's decision.
Present law provides that the director of the office of workers' compensation (OWCA) may
hire a medical director and associate medical director to render decisions on disputed cases.
Present law provides for the development of a medical treatment schedule based on
conscientious, explicit, and judicious use of current best evidence about the care of patients.
Present law authorizes a review and update of the medical treatment schedule no less than
every 2 years.
Present law provides that all medical care and treatment due after the promulgation of the
medical treatment schedule shall be in accordance with the medical treatment schedule.
Proposed law clarifies that the date before which an accident or injury would have to have
occurred to not be required to be treated in accordance with the medical treatment schedule
is July 13, 2011. HLS 14RS-1729 ORIGINAL
HB NO. 1190
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Present law provides that after a medical provider has submitted a request for authorization
as required to the payor, that the payor shall notify the provider of his action on the request
within 5 business days of receipt of the request.
Proposed law retains present law and further provides that any request for authorization that
is not specifically denied within the five business days as required in present law shall be
authorized and paid by the payor.
Present law specifies that if any dispute arises after Jan. 1, 2011 as to whether the
recommended treatment is in accordance with the medical treatment schedule or whether a
variance in treatment is appropriate, any aggrieved party shall file an appeal with the medical
director.
Proposed law revises present law by deleting the Jan. 1, 2011 date and specifically providing
that the payor shall file the appeal instead of "any aggrieved party".
Present law allows for the filing of an appeal by LWC Form 1008, "Disputed Claim for
Compensation".
Proposed law retains present law and further requires that the Form 1008 be filed within 30
days of the issuance of the decision of the medical director.
Present law allows the decision to be overturned by clear and convincing evidence that the
decision was not in accordance with present law.
Proposed law changes the evidential standard from clear and convincing to a preponderance
of the evidence.
Proposed law allows any competent, relevant evidence at the hearing of appeal.
Proposed law requires that the OWCA director be notified that an appeal has been filed
within 10 days.
Proposed law requires the director to compile and forward the entire record reviewed by the
medical director to the district hearing office within fifteen days of receiving notice.
Proposed law further requires the record to be made available to the parties to the appeal
upon request.
Present law provides that all treatment not specified in the medical treatment schedule shall
be due by the employer when a preponderance of scientific medical evidence supports
approval of the treatment.
Proposed law repeals present law.
(Amends R.S. 23:1203.1(I), (J)(1), (K), and (M))