Navigating the Louisiana UR Rules and the Approval/Appeal Process

1. Navigating the Louisiana UR Rules and the Approval/Appeal Process Presented by: Jamie R. Bourg, Claims Manager Large Accounts Dr. Kate Rathbun, Medical Director LWCC August 23, 2013

2. Outline • LWCC Claims Structure • Medical Treatment Guidelines • Utilization Review

3. LWCC Claims Structure • 2 Teams • Large Accounts • Jamie Bourg, Claims Manager • Linda Dantin, Claims Supervisor • Small & Medium Accounts • Kathy Otts, Claims Manager • Nathan Lepine, Claims Supervisor

4. LWCC Claims Structure • Functions in each team: • ICR—Investigative Claims Rep • RTW—Return to Work Claims Rep • M&M—Medical Only & Maintenance Rep • RCR—Resolution Claims Rep • CS—Claims Specialist • AS—Account Specialist

5. LWCC Claims Structure • Medical Services Team • Stacy Guillory—Clinical Services Supervisor • Medical Case Coordinators • Kimberly Sanders, RN • Vanessa Keith, RN • DME Coordinator—Angela Aranyosi • Pharmacy Coordinator—Keisha Joseph

6. Medical Treatment Guidelines • Became effective July 15, 2011 • Guidelines are available online: • http://www.laworks.net/WorkersComp/OWC_MedicalGuidelines.asp

7. Medical Treatment Guidelines • Contains 4 main parts • Spine Guidelines • Pain Guidelines • Neurological & Neuromuscular Guidelines • Upper and Lower Guidelines

8. Utilization Review • Adopted by Louisiana Workforce Commission (LWC) Office of Workers’ Compensation Administration • Became effective April 20, 2012 • U/R rules apply to nonemergency service >$750 per provider per claim • Applies to LA state claims. Does not apply to longshore claims.

9. Utilization Review • All requests for authorization MUST be made using LWC Form 1010. • Links for the forms: • www.laworks.net/Downloads/OWC/1010form.pdf • www.laworks.net/Downloads/OWC/1010Aform.pdf

10. Utilization Review • All 1010s must be sent to a centralized fax or email. • LWCC’s fax and email are: • Fax 225-231-8415 • Email lwccur@lwcc.com

11. Utilization Review • Providers should include the following information on the 1010 form: • History provided to the level of condition and as provided by Medical Treatment Schedule • Physical findings/clinical tests • Documented functional improvements from prior treatment • Test/imaging results • Treatment plan including services being requested along with the frequency and duration

12. Utilization Review • Additional information needed from the provider on the 1010 form: • Include description of items to be reviewed with the CPT codes. • When requesting surgery, include all additional services related to the surgery, such as: • Home health • DME • PT

13. Utilization Review • Information needed for subsequent request for treatment on 1010: • Any updated medical records from the physician • Complete evaluation and documentation of active treatment

14. Utilization Review • Who files 1010s for the recommended treatment? • The treating HCP is responsible for completing the 1010. • Facilities where the services are to be rendered, i.e. PT/OT clinics, can submit a 1010 with all the appropriate information.

15. Utilization Review • Once a 1010 is received by LWCC: • It is reviewed for compensability. • If it is a compensable claim, Mitchell will handle the utilization review process. • Mitchell has 5 business days to render a decision or request additional information.

16. Utilization Review • LWCC has 10 calendar days to voluntarily reconsider a denial of treatment. • Reconsideration can be through a peer-to-peer review.

17. Utilization Review • Office visits: • 1010s are not required for initial evaluation as this is a choice of physician issue. • 1010s may be required for subsequent visits if the proper documents (functional improvement, work limitations, etc.) are not provided. • In most cases, verbal authorization will be given for office visits.

18. Utilization Review • Pharmacy: • For LWCC, 1010s are not required for prescription medications. • All pharmacy transactions are through our PBM, Healthesystems. • Depending upon the type of medication, a letter of medical necessity may be required before approval of the medication is given.

19. Utilization Review • Disputes regarding UR decisions • Addressed by filing LWC Form 1009 • http://www.laworks.net/Downloads/OWC/1009form.pdf • Aggrieved party has 15 calendar days from the date of the decision to file. • Once filed, the OWC Medical Director has 30 calendar days to issue a decision. • Either party in disagreement with the Medical Director’s decision has 15 calendar days to file an LWC Form 1008.

20. Utilization Review • Disputes regarding UR decisions • If a 1009 is filed, a copy must be sent to all parties. • Issues of compensability and causation are not resolved through the 1009 process.

21. What does all this mean? • 1010s must be completed. • Must include all the information listed on the 1010 form. • Cannot just be the 1010 form and script for the service requested. • If you disagree with our UR decision, a 1009 can be filed.

22. What does all this mean? • Continue to educate yourself about the guidelines and UR process. • Use us as a resource!

23. QUESTIONS?

24. References • http://www.laworks.net/WorkersComp/OWC_MedicalGuidelines.asp • http://www.laworks.net/Downloads/OWC/MedicalGuidelines_MedicalTreatmentGuidelineFAQs.pdf