Louisiana

- In 2014 Louisiana became the sixth state to pass DPC legislation with Senate Bill No. 516.  The law has now been made a part of the Louisiana Revised Statutes sections 37:1360.81 through 1360.91.  The links to each section of the law are as follows:

• §1360.81. Definitions

• §1360.82. Prohibition on discrimination

• §1360.83. Direct fee

• §1360.84. Prohibited and authorized practices

• §1360.85. Acceptance or discontinuation of care of patients; third-party payments

• §1360.86. Direct practice not an insurer

• §1360.87. Conduct of business; prohibitions

• §1360.88. Misrepresenting the terms of a direct agreement

• §1360.89. Direct agreement requirements; disclaimer

• §1360.90. Rules

• §1360.91. Violations

- Louisiana's "Direct Primary Care Practice" laws were the best legislative example at the time of their passage.  These laws appropriately protected DPC physicians from "business of insurance" accusations and provided a reasonable definition of DPC.  The legislation stopped short of using language to clarify DPC from concierge practices.    At the time, Louisiana was the first state to pass DPC legislation without any legislative resistance or DPC practice "business of insurance" allegations from the office of the state insurance commissioner.  A white paper about DPC prepared by Flood International Consulting Agency was likely helpful for the legislators.  In spite of this legislation one should still review the Louisiana Insurance Code when setting up a practice.  

- Multiple DPC practices are now operating within the state of Louisiana and the Louisiana Academy of Family Physicians openly promotes and supports direct primary care.  A Louisiana Direct Primary Care Coalition has formed as well and they are a great resource for physicians considering DPC in Louisiana.  

- In office dispensing in Louisiana can be a bit onerous.  The Louisiana State Board of Medical Examiners lists their requirements for obtaining a permit on their website (scroll half way down the page under "other forms / applications" to find the dispensing physician permits).  Here are the highlights:

1) You must pay a $75.00 application fee, and a $50 (presumably yearly) fee for each renewal period
2) Controlled substances are difficult to dispense (probably a good thing) - limited to 48 hour supply, this option is only available to physicians that have been in practice for greater than three years
3) The initial application asks that you "list all medications proposed to be dispensed. Include brand or generic name, CDS schedule, dosage, quantity."

For full details you will also want to read Chapter 65 of Title 46 Professional and Occupational Standards (starting on page 37 of this link).  Note the detailed requirements in Subchapter D (Record keeping of purchases, acquisitions, medication inventories, dispensation records, other transaction records, computerized records, and retention of records), Subchapter E (labeling and packaging) and Subchapter F (Security).  

Louisiana Medicaid - Here is a link to the Louisiana Medicaid Provider Manual. There is a promising phrase under Section 5.1 Acute Hospital Precertification "Physician Billing When Pre-Certification Is Not Authorized." "A provider may bill the Medicaid recipient when the recipient presents to the hospital as a private-pay patient and does not inform the hospital of his/her Medicaid coverage." This enrollment form includes two problematic phrases:

“18. I agree to participate as a provider of medical services and shall bill Medicaid for Medicaid covered services performed on behalf of an eligible individual who has been accepted by me as a Medicaid patient;”

“19. I agree to accept Medicaid payment for covered services as payment in full and not seek additional payment from any recipient for any unpaid portion of a bill, with the exception of state-funded spend-down Medically Needy recipients as indicated by the agency’s form 110-MNP or any recipient co-payments as established by LDH;”

Later Louisiana did add an ORP enrollment option. Thank you to Jeremy Snavely at AAPS for his excellent analysis of this option:

“  "Enrolling as a FFS Medicaid OPR Provider:

• Does not obligate you to see Medicaid patients;

• Does not mean you will be listed as a Medicaid provider for patient assignment or referral;

• Does not, at this time, require an annual renewal;

• Allows you to continue to see Medicaid patients without billing the Medicaid program if you so choose; and,

• Helps ensure that your orders, prescriptions, and referrals for Medicaid patients are accepted and processed appropriately

On the down side, it states that the ORP enrollee will:

• Allow for inspection of all records by governmental authorities;

• and inspection of facilities;

• agree to charge no more for services to eligible recipients than is charged on the average for similar services to others; [this one wouldn't be a problem for cash practice that charges everyone the same fees, also doubtful that Medicaid pts could pay more anyhow]

Also perhaps problematic:

• I understand that as the provider, I am held responsible for any and all claims associated under the Louisiana Medicaid provider number issued to me; [I read this as including responsibility in cases where the state doesn't like some of the drugs it paid for subsequent to a prescription by a doctor with ORP status.]

• I agree to maintain all records necessary for full disclosure of services provided to individuals under the program and to furnish, at no cost, information regarding those records as well as payments claimed/received for providing such services that DHH, the DHH Secretary, the Louisiana Attorney General, or the Medicaid Fraud Control Unit may request for five years from the date of service;

• I agree to submit all requested medical records within the time frames allowed

• I agree to adhere to the federal Health Insurance Portability and Accountability Act (HIPAA) and all applicable HIPAA regulations issued by the federal DHHS”