La. Admin. Code tit. 40 § I-2519

Current through Register Vol. 50, No. 9, September 20, 2024

Section I-2519 - Outlier Reimbursement and Appeals Procedures

A. Automatic Outliers. Inpatient hospital acute care services falling within certain diagnosis code ranges will be reimbursed outside the normal per diem reimbursement method. These atypical admissions will be paid at covered billed charges less a 15 percent discount. Conditions requiring acute care inpatient hospital services that are work-related and are recognized as "automatic outliers" are:

1. AIDS: ICD-10 diagnosis code B20;

2. Acute Myocardial Infarction: ICD10 diagnosis codes: I213, I214, I220, I221, I222, I228, I229; I2101, I2102, I2109, I2111, I2119, I2121, I2129; and

3. severe burns: ICD-10 diagnosis codes: T2030XA, T20311A, T20312A, T20319A, T2032XA, T2033XA, T2034XA, T2035XA, T2036XA, T2037XA, T2039XA, T2070XA, T20711A, T20712A, T20719A, T2072XA, T2073XA, T2074XA, T2075XA, T2076XA, T2077XA, T2079XA; T2130XA, T2131XA, T2132XA, T2133XA, T2134XA, T2135XA, T2136XA, T2137XA, T2139XA, T2170XA, T2171XA, T2172XA, T2173XA, T2174XA, T2175XA, T2176XA, T2177XA, T2179XA; T2230XA, T22311A, T22312A, T22319A, T22321A, T22322A, T22329A, T22331A, T22332A, T22339A, T22341A, T22342A, T22349A, T22351A, T22352A, T22359A, T22361A, T22362A, T22369A, T22391A, T22392A, T22399A, T2270XA, T22711A, T22712A, T22719A, T22721A, T22722A, T22729A, T22731A, T22732A, T22739A, T22741A, T22742A, T22749A, T22751A, T22752A, T22759A, T22761A, T22762A, T22769A, T22791A, T22792A, T22799A; T23301A, T23302A, T23309A, T23311A, T23312A, T23319A, T23321A, T23322A, T23329A, T23331A, T23332A, T23339A, T23341A, T23342A, T23349A, T23351A, T23352A, T23359A, T23361A, T23362A, T23369A, T23371A, T23372A, T23379A, T23391A, T23392A, T23399A, T23701A, T23702A, T23709A, T23711A, T23712A, T23719A, T23721A, T23722A, T23729A, T23731A, T23732A, T23739A, T23741A, T23742A, T23749A, T23751A, T23752A, T23759A, T23761A, T23762A, T23769A, T23771A, T23772A, T23779A, T23791A, T23792A, T23799A; T24301A, T24302A, T24309A, T24311A, T24312A, T24319A, T24321A, T24322A, T24329A, T24331A, T24332A, T24339A, T24391A, T24392A, T24399A, T24701A, T24702A, T24709A, T24711A, T24712A, T24719A, T24721A, T24722A, T24729A, T24731A, T24732A, T24739A, T24791A, T24792A, T24799A; T25311A, T25312A, T25319A, T25321A, T25322A, T25329A, T25331A, T25332A, T25339A, T25391A, T25392A, T25399A, T25711A, T25712A, T25719A, T25721A, T25722A, T25729A, T25731A, T25732A, T25739A, T25791A, T25792A, T25799A; T2600XA, T2601XA, T2602XA, T2610XA, T2611XA, T2612XA, T2620XA, T2621XA, T2622XA, T2630XA, T2631XA, T2632XA, T2640XA, T2641XA, T2642XA, T2650XA, T2651XA, T2652XA, T2660XA, T2661XA, T2662XA, T2670XA, T2671XA, T2672XA, T2680XA, T2681XA, T2682XA, T2690XA, T2691XA, T2692XA; T270XXA, T271XXA, T272XXA, T273XXA, T274XXA, T275XXA, T276XXA, T277XXA; T281XXA, T282XXA, T283XXA, T2840XA, T28411A, T28412A, T28419A, T2849XA, T285XXA, T286XXA, T287XXA, T288XXA, T28911A, T28912A, T28919A, T2899XA; T300; T304; T310, T320; T3110, T3210; T3111, T3211; T3120. T3220; T3121, T3221; T3122, T3222; T3130, T3230; T3131, T3231; T3132, T3232; T3133, T3233; T3140, T3240; T3141, T3142, T3143, T3243; T3144, T3244; T3150, T3250; T3152, T3252; T3151, T3251; T3154, T3254; T3153, T3253; T3155, T3255; T3160, T3260; T3161, T3261; T3162, T3262; T3163, T3263; T3164, T3264; T3165, T3265; T3166, T3266; T3170, T3270; T3171, T3271; T3172, T3272; T3173, T3273; T3174, T3274; T3175, T3275; T3176, T3276; T3177, T3277; T3180, T3280; T3181, T3281; T3182, T3282; T3183, T3283; T3184, T3284; T3185, T3285; T3186, T3286; T3187, T3287; T3188, T3288; T3190, T3290; T3191, T3291; T3192, T3292; T3191, T3293; T3194, T3294; T3196, T3296; T3195, T3295; T3197, T3297; T3198, T3298; T3199, T3299.

B. Appeal Procedures. Special reimbursement consideration will be given to cases that are atypical in nature due to case acuity causing unusually high charges when compared to the provider's usual case mix. This appeal process applies to workers' compensation cases paid under the per diem reimbursement formula limiting the payment amount to the lesser of per diem or covered billed charges.

1. The following general criteria will be applied to determine when a case, originally paid at the per diem rate, may be appealed:

a. total charges for an inpatient hospital surgical admit are greater than or equal to $100,000;

b. total charges for an inpatient hospital medical admit are greater than or equal to $75,000;

c. average per day charge for any case (inpatient hospital, rehabilitation, SNF, etc.) equates to 1.75 times the applicable per diem rate.

2. When a provider determines that a case falls within the appealable criteria, a request for review may be submitted to the carrier/self-insured employer.

3. If denied, a provider may then file a formal appeal with the Office of Workers' Compensation using the Special Reimbursement Consideration Appeal Form (LDOL-WC-3000) (see §2519. B.7.a Exhibit II). Forms are available upon request from the Office of Workers' Compensation at the address shown on the sample form. Procedures for filing an appeal and documentation required are provided on the form.

4. Final determination as to acceptance of a case for special reimbursement rests solely with the state of Louisiana, Office of Workers' Compensation.

5. If approved, the provider will be reimbursed at covered billed charges less a 15 percent discount.

6. The formula for calculation of the reimbursement amount for both automatic outliers and approved appeal cases is:

(Billed Charges) - (Noncovered Charges) = Covered Charges x 0.85 = Payment Amount

7. All workers' compensation claims paid outside the per diem reimbursement method either as automatic outliers or as Special Reimbursement Consideration Appeal cases are subject to on-site bill audit. Bill audits are governed by the rules and procedures found in the Utilization Review Procedures Manual. Please refer to that manual for details.

a. Exhibit II

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La. Admin. Code tit. 40, § I-2519

Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:54 (January 1993), repromulgated LR 19:212 (February 1993), amended LR 20:1299 (November 1994), Amended by the Workforce Commission, Office of Workers Compensation, LR 41981 (5/1/2015), Amended by the Workforce Commission, Office of Workers Compensation Administration, LR 42283 (2/1/2016).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.