Bill
SB 408
Louisiana SB 408 modernizes workers’ comp by basing reimbursements on Louisiana data (75th percentile), creating a mandatory All Medical Claims Database, and mandating electronic b
Jurisdiction: Louisiana
Title: WORKERS' COMPENSATION: Provides relative to the workers' compensation reimbursement schedule. (gov sig)
Author/Sponsor: Senator Myers (co-sponsor: Brach Myers)
Purpose and intent
- The bill preserves and modernizes Louisiana’s workers’ compensation reimbursement framework. It introduces a Codes-based reimbursement methodology, creates a comprehensive All Workers’ Compensation Medical Claims Database, strengthens data reporting and confidentiality protections, enhances dispute resolution related to billing and payments, and sets a schedule for updating the medical fee schedule using Louisiana-specific data.
Key provisions and changes
1) Reimbursement schedule for medical services (Chapter 10 / Part 1)
- Reimbursement is to be determined using CPT/HCPCS codes when applicable.
- The base reimbursement amount for professional services, care, treatment, drugs, and supplies shall be set at the 75th percentile of the PMIC Medical Fees Directory (with alternatives for non-listed CPT codes using comparable codes).
- For inpatient/outpatient hospital services and ambulatory surgery, reimbursement shall be the 75th percentile of amounts paid for similar services reflected in the All Workers' Compensation Medical Claims Database (latest 24 months).
- No “by report” billing allowed (i.e., reimbursement cannot be based on discretionary reporting without a code).
- Major annual change cap: any increase or decrease in a CPT/HCPCS/facility/reimbursement category cannot exceed 5% in any 12-month period unless:
- Material access-to-care deficiencies are demonstrated, or
- Clear actuarial evidence of system imbalance, or
- Legislative concurrent resolution approves.
- Any decrease must be phased in over at least two years.
- Within the first 36 months after the initial fee schedule, a one-time corrective adjustment in excess of 5% may be proposed if:
- An independent actuary finds initial benchmarks materially inaccurate,
- Senate and House labor committees jointly approve,
- The adjustment is non-repeatable.
- Fee schedule updates: Office of Workers’ Compensation Administration shall review and update fee schedules every two years.
- Implant reimbursement: implants reimbursed at total of original manufacturer/distributor invoice paid plus 20%.
2) All Workers' Compensation Medical Claims Database (New Subpart K)
- Establishes and maintains the All Workers' Compensation Medical Claims Database.
- Purpose: enhance transparency, enforce a fair fee schedule, analyze utilization and outcomes, detect fraud/waste/abuse, and support policy development and oversight.
- Mandatory reporting: Beginning Jan 1, 2027, all payors must submit medical and pharmacy claims data for all Louisiana workers' compensation claims.
- Data elements: injury date, employer industry, provider specialty/identifier, CPT/HCPCS/NDC/ICD codes, billed/allowed/paid amounts, service dates, utilization review actions, claim status indicators.
- Confidentiality: data are confidential and privileged; public reports will be aggregated/de-identified. Violations are misdemeanors with penalties.
- Authorized uses: monitor fee schedule compliance, study cost drivers/utilization trends, support actuarial rate analysis, evaluate treatment guideline effectiveness, develop/modernize the fee schedule, and annual reporting to the Legislature.
- Data integrity: issuers may be audited; noncooperation can trigger daily fines up to $10,000; ongoing cooperation required.
- Data security: HIPAA and privacy protections apply; penalties for improper disclosure.
- Data submission timeline: quarterly submissions, unless rules specify otherwise.
3) Electronic medical billing and prior authorization (R.S. 23:1203.2)
- Beginning Oct 1, 2026, medical service claims must be submitted electronically.
- The assistant secretary will set rules for electronic claims, processing, and payment (837 format or successor).
- Prior authorization portal may be created to streamline approvals; pilot programs may be used before statewide implementation.
- Treating physician referrals: payors must authorize referrals or provide a written denial with clinical justification within 10 business days; failure to respond within the timeline is deemed authorization.
4) Other administrative and legal provisions
- Revisions to penalty provisions for late payments; civil fines range from $1,000 to $5,000 for late payments.
- Public records: the All Workers' Compensation Medical Claims Database is added to public records exemptions.
- Effective date: Overall act becomes effective upon gubernatorial signature or as provided by law, with certain sections subject to specific staged effective dates (including the database rules and fee schedule updates).
Who is affected
- Workers' compensation payors (employers, insurers) must adopt electronic billing and submit data to the new database.
- Healthcare providers and suppliers receiving workers' compensation payments will be reimbursed under the new 75th percentile-based schedule.
- The Louisiana Works, office of workers' compensation administration (OWCA) is given expanded duties (data collection, analysis, rulemaking, oversight, and data privacy).
- Legislators and committees (labor and industrial relations) gain a framework for oversight of fee schedule updates.
Procedural/timeline aspects
- 2026: Electronic billing rules become effective for claims; prior authorization portal may be piloted.
- 2027: Mandatory data submission to the All Workers' Compensation Medical Claims Database begins.
- Every two years: OWCA to review and update fee schedules based on the new data.
- 2028: Progress reporting on the updated fee schedule methodology required.
- Ongoing: Confidentiality protections, audits, and penalties for noncompliance.
Effective date
- The act’s provisions generally take effect upon signature by the governor or the expiration of the period for gubernatorial action; certain sections have staged or contingent effectiveness tied to the rulemaking and reporting schedule.
Note
- The bill emphasizes Louisiana-specific data for fee setting, greater transparency, mandatory data reporting, stronger enforcement for late payments, and a modernization of the medical fee schedule with a data-driven approach.
Compiled from official sources — confirm details with the bill’s official record.
Sign in to ask a question.
