RÉSUMÉ DIGEST
ACT 187 (HB 353) 2020 Regular Session Brown
Relative to dental services, new law defines "downcode" or "downcoding" and "regular fee".
New 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 new law to be an unfair or deceptive practice subject to the penalties in
existing law relative to unfair trade practices.
New law prohibits a dental service contractor from changing a procedure code submitted by
a dentist or other healthcare provider unless both 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.
New 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
was unrelated 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.
New 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.
New law prohibits a dental service contractor, insurer, or other third-party payer from
downcoding the installation service of a fixed bridge to a removable bridge.
Effective Aug. 1, 2020.
(Adds R.S. 22:1151(7) and (8) and 1157.1)