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)]
HB 353 Original 2020 Regular Session Brown
Abstract: Prohibits downcoding of claims for dental services unless specific criteria are met.
Proposed law defines "downcode" or "downcoding" as the alteration by a dental service contractor,
insurer, or other third-party payer of a service code submitted with a claim for reimbursement by a
dentist or other healthcare provider to one of lesser complexity, resulting in decreased
reimbursement.
Proposed law prohibits a dental service contractor from systematically downcoding with the intent
to deny reimbursement otherwise due to a dentist or other healthcare provider and deems a violation
of proposed law to be an unfair or deceptive practice subject to the penalties in present law relative
to unfair trade practices.
Proposed law prohibits a dental service contractor from changing a procedure code submitted by a
dentist or other healthcare provider unless all of the following conditions are met:
(1)The change is consistent with the dental service contractor's policies.
(2)The dental service contractor has sufficient information to make the change.
(3)The dental service contractor has consulted with the submitting dentist or other healthcare
provider prior to the change.
Proposed law requires the explanation of benefits (EOB) provided to the subscriber to include the
reason for the downcoding and citation of the dental service contractor's applicable policy and
prohibits the EOB from stating or inferring either of the following:
(1)That the code billed by the dentist or other healthcare provider was inappropriate unless there
is clear evidence the code listed on the claim by the dentist or provider in no way related to
the procedure actually performed.
(2)That the dentist or other healthcare provider's charge was excessive unless there is clear
evidence the charge was substantially higher than the dentist's or provider's regular fees.
Proposed law requires the dental service contractor to disclose in its provider contracts, on its
website, or both, the specific downcoding policies that the dental service contractor reasonably
expects to be applied to the provider or provider's services on a routine basis as a matter of policy. (Adds R.S. 22:1151(7) and (8) and 1157)