§1825. Billing audit guidelines, rules, and regulations

A. The commissioner shall, with the consent of the Louisiana Department of Health and in compliance with the Louisiana Administrative Procedure Act, issue such rules, regulations, and orders as shall be necessary to implement a statewide system of billing audit guidelines of health care bills for medical and clinical items and their reimbursement by insurers, health maintenance organizations, preferred provider organizations, self-insured plans, or any other medical expense plan or contract.

B. The rules, regulations, or orders required by Subsection A of this Section shall determine:

(1) The need to bill or rebill a payor of medical or clinical care charges that were not initially incorporated on a reimbursement or payment claim by a provider.

(2) The need to adjust reimbursements and payments undertaken by the payor for items or services that were insufficiently documented.

(3) The need to periodically validate the accuracy of the billing process between provider and payor.

C. The rules, regulations, and orders required by Subsection A of this Section shall include but not be limited to the following parameters:

(1) Exceptions to the rules, regulations, and orders in cases where there exists a negotiated contract between the auditing parties.

(2) An audit fee of one hundred dollars.

(3) Initial payment criteria and alternatives available upon mutual agreement.

(4) Guidelines and qualifications of both internal and external auditors.

(5) Provisions for the payment for any identified unsupported or unbilled charges discovered by the audit parties.

D. The term "billing audit" means a process to determine whether data in a health care record of a provider is supported by services or treatments listed on the bill issued by the provider.

Acts 1993, No. 664, §1; Redesignated from R.S. 22:12 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2012, No. 271, §1.