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Louisiana’s Work Comp Legal Landscape

Louisiana’s Work Comp Legal Landscape. Presented by: Terrel Thomas Managing Attorney Johnson, Rahman & Thomas In-house counsel for LWCC. AGENDA. Emerging Topics in Workers’ Compensation Court. 1. Medical Providers’ Role in the System 2. Fraud in the Workers Comp Arena

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Louisiana’s Work Comp Legal Landscape

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  1. Louisiana’s Work Comp Legal Landscape Presented by: Terrel Thomas Managing Attorney Johnson, Rahman & Thomas In-house counsel for LWCC

  2. AGENDA Emerging Topics in Workers’ Compensation Court • 1. Medical Providers’ Role in the • System • 2. Fraud in the Workers Comp Arena • Treatment Guidelines-What • happens in Court? • 4. La. Second Injury Fund

  3. A Medical Provider’s Role in the System

  4. La. R.S. 23:1203Duty to furnish medical & voc. rehab expenses, … A. The employer shall furnish all necessary drugs, supplies, hospital care and services, medical and surgical treatment, and any nonmedical treatment recognized by the law of this state as legal.

  5. Medical Records HIPAA and Workers Compensation Act

  6. Medical Records Release of Medical Records and Information La. R.S. 23:1127

  7. Fraud In the early 1990s, WC insurance was so expensive it was driving businesses out of Louisiana and dampening employment rates. Laws concerning fraud help prevent rising insurance costs and deter false claims.

  8. What is Workers Compensation Fraud? It’s not just injured workers committing fraud….

  9. Medical records help prove whether a work accident occurred.

  10. Fraud Surveillance Review

  11. Medical Treatment Guidelines What happens when the 1009 denials are before the Workers Comp Judge?

  12. Procedure • 1008 Appeal • Anyone who disagrees with the Medical Director’s decision can file a Disputed Claim (LWC-1008) with the Office of Workers Compensation.

  13. When is a claim“PREMATURE”? You must go through the 1009 process before you can file a Disputed Claim Form (1008)

  14. Stale Evidence Keep your records up to date No testimony or records allowed as new evidence

  15. Provide Appropriate Documentation Must provide functional improvement and results of physical therapy or rehab

  16. Provide Appropriate Documentation Follow the MTG to support your recommendation

  17. Burden of Proof at 1009 Appeal Hearing Clear and Convincing Evidence

  18. Definition of “clear and convincing” “more than a mere preponderance but something just short of conclusive (beyond a reasonable doubt” in criminal cases). In reality, “clear and convincing” burden of proof generally requires proof which leaves no reasonable doubt concerning the truth of the matters at issue.

  19. Judge overturns denial Submit enough information with the 1009 for the Medical Director to review

  20. Second Injury Fund (SIF) • Encourages employers to hire people with pre-existing conditions despite the risk that the employee could suffer a substantially more disabling and more costly work injury.

  21. Qualifications for Reimbursement • 1. Pre-existing Permanent Partial • Disability (PPD) • 2. Employer has prior Knowledge of • PPD • Merger of pre-existing condition • and subsequent work injury

  22. What is Permanent Partial Disability? A permanent condition that poses a hindrance or obstacle to obtaining or retaining employment.

  23. Presumed Conditions RS 23:1378(F) • Seizure Disorder 18. Muscular Dystrophy • Diabetes Mellitus 19. Arteriosclerosis • Coronary Artery Disease/ 20. Thrombophlebitis • Congestive Heart Failure 21. Varicose Veins • Arthritis 22. Heavy Metal Poisoning • Amputation 23. Ionizing Radiation In • Loss of sight or legal blindness 24. Compressed Air Sequelae • Disability from Polimyelitis 25. Ruptured/Herniated Disc • Cerebral Palsy 26. Brain Damage • Multiple Sclerosis 27. Spinal Surgery • Parkinson’s Disease 28. Chronic Obstructive • Cerebral Vascular Accident Pulmonary Disease • Tuberculosis 29. PTSD • Pneumoconiosis 30. Post Concussive Syndrome • Psychoneurosis/Psychosis 31. Alzheimer’s Disease • Bleeding Disorder 32. Sicle Cell Anemia • Chronic Osteomyelitis 33. Joint Replacement Surgery • Ankylosis of Joint 30(a). Mental Retardation

  24. Merger Employers/Insurers need physicians to show how the pre-existing condition affected the severity, recovery and cost of the work injury. • But For Merger • “But for” the pre-existing condition, the work injury would not have occurred.

  25. Merger Employers/Insurers need physicians to show how the pre-existing condition affected the severity, recovery and cost of the work injury. 2. Combination of PPD and Work Injury to create a materially and substantially greater disability than would have occurred from the work injury if the PPD did not exist

  26. Merger Employers/Insurers need physicians to show how the pre-existing condition affected the severity, recovery and cost of the work injury. Examples

  27. Questions?

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