LEMLA questions and answers
What is the purpose of the Law Enforcement Medical Liability Account (LEMLA)?
LEMLA provides a fund for reimbursing medical providers for medical services provided to an individual for "injuries related to law enforcement activity".
What does "injuries related to law enforcement activity" mean?
It means injuries sustained prior to booking, citation in lieu of arrest or release instead of booking that occur during, and as a result of, efforts by a law enforcement officer to restrain or detain, or to take or retain custody of, the individual. It does not include treatment for injuries that are not related to efforts by the law enforcement officer to restrain or detain, or to take the individual into custody. The law enforcement agency will make the decision as to whether the injuries are related to law enforcement activity.
Example of injuries that would be covered:
- Police dog bites sustained by a suspect during the course of apprehending the individual.
- Injuries sustained by a suspect as a result of a motor vehicle accident that occurred during police pursuit.
- Gun shot wounds inflicted by a police officer attempting to apprehend the individual.
- Injuries to a suspect caused by the law enforcement officer due to the use of any force to effectuate the arrest.
Examples of injuries that would not be covered:
- Injuries sustained by an innocent bystander as a result of police action to apprehend a suspect.
- Injuries sustained by an innocent bystander as a result of the suspect’s actions.
- Injuries sustained in a motor vehicle accident caused by an individual who is DUII, when the
individual was not subject of law enforcement activity to restrain or detain, or to take or retain
custody of, the individual, prior to the accident.
- Injuries sustained by the suspect during the commission of the crime prior to the law enforcement action such as falls, cuts, burns, and other injuries.
- Medical services that are unrelated to injuries that are covered, such as a pre-existing disease
or condition. For example, if an individual being treated for a police dog bite is determined to
already have an illness, the injury from the dog bite is covered, but treatment for the illness is not.
- Follow-up services for an individual that occur after the individual has been released from actual physical custody. This might include suture removal, cast removal, additional x-rays, or physical therapy.
Who are claimants?
To be eligible for payments from the account the medical provider must have a Medicaid provider number. If you don’t have a Medicaid provider number or you’re not sure of your number, contact LEMLA for assistance.
How much collection effort must be made before billing LEMLA?
Medical providers must make every reasonable effort to collect from the individual, the individual’s insurer, or health care contractor.
When should a claim be filed?
Medical providers may file a claim with LEMLA if they have not been paid within 45 days after billing the patient or the patient’s health care contractor. Claims, however, must be received by LEMLA within one year after the date of injury.
What are the requirements for a valid claim?
Hospitals and other medical providers must submit a copy of a detailed billing along with documentation that a reasonable effort has been made to collect from the patient or the patient’s insurer or health care contractor. Providers must also provide the claim amount, the amount collected prior to billing LEMLA, the date of the injury, patient’s name, address of patient, cause/nature of injury, the provider’s Medicaid number, and the provider’s name.
In addition to the above requirements, the authorized representative of the law enforcement agency must certify that the claim is for injuries related to law enforcement activity. The law enforcement agency must also provide the date the LEMLA patient was released from actual physical custody. If the LEMLA patient remained in actual physical custody throughout the period covered by the claim, the law enforcement agency should report this on the claim form.
Where should the claim be filed?
After attaching the required documentation, medical providers should forward the LEMLA claim and all attachments to the law enforcement agency involved in the injury. Contact LEMLA if you need assistance in determining where to forward the claim.
What happens to the claim next?
The authorized representative of the law enforcement agency will determine whether the injuries are related to law enforcement activity and the date the LEMLA patient was released from actual physical custody. After this information is added, the claim will be sent by the law enforcement agency to LEMLA for processing.
Who administers LEMLA?
The Oregon Health Authority, Medical Assistance Program, administers this dedicated fund account.
What amount will LEMLA pay?
All providers will bill the usual amount billed to the general public. Hospitals will be paid according to the current fee schedules established by the Department of Consumer and Business Services for the purposes of workers’ compensation. All other providers will be paid 75% of the billed amount.
When will LEMLA pay the claim?
Claims are reviewed and processed by LEMLA as soon as they are received. Payments for approved claims are mailed to providers at the end of each month. LEMLA will make every effort to process and pay claims in the same month they are received.