Tennessee Workers Compensation Law Utilization Review

As a workers compensation attorney who assists injured workers for injuries sustained in course of employment, the utilization review is the most difficult and absurd element of workers compensation law one must contend with. Where in the course of medical treatment and in the universe of healthcare can a registered nurse dictate what is medically necessary and reasonable while and trumping the diagnosis and recommendation of an authorized treating physician or surgeon? In the scope of my workers compensation practice, I contend daily with utilization reviews and bureaucratic appeals to protect the medical benefits injured employees are entitled to by law. Governor Bredesen signed this legislation that overhauled workers compensation law all in the name of industrial development. Insurance companies literally have a registered nurse in a cubicle reading medical records with no personal examination of the patient dictating the course of medical treatment by finding any technical means to invalidate a course of medical treatment sought by the authorized treating physician who is loyal to the insurance company to begin with. They refer to medical treatises that are objective to a particular medical code or pathology which has no subjective evaluation of the individual patient. The following is a synopsis of the utilization review process that requires an injured worker to hire the appropriate attorney to protect and maximize his or her benefits.

The “UR” system provides for:

• Review of selected outpatient and inpatient health care providers; andPre-admission review of all hospital admissions, except for emergency services.
• Utilization review is required in every case where the medical necessity of a recommended treatment is disputed.
• Utilization review services must be provided or contracted for/by:

1. Each insurer who provides workers’ compensation insurance in Tennessee.
2. Every self-insured employer.

• The insured employer may choose to provide the services on its own or though a third party administrator.
• The UR Agent conducting the review services must be registered with the Division of Workers’ Compensation.
• Recommended treatments may only be denied by an Advisory Medical Practitioner (an actively TN-licensed practitioner, who is board-certified and in the same or similar general specialty as the authorized treating physician). Recommended treatments may be approved by an Advisory Medical Practitioner or registered nurse. UR Agents may employ or contract with individual Advisory Medical Practitioners and registered nurses.

• The UR rules, Chapter 0800-02-06 provide for specific timeframes in which to complete UR and to notify the parties of the UR determination.
• A health care provider who is found to have rendered excessive or inappropriate services may be subjected to:

1. Forfeiture of the right to payment for the services rendered;
2. Payment of civil penalty of up to $1,000;
3. Temporary or permanent suspension of the right to provide medical care services for workers’ compensation claims.

• An employer, insurer, third party administrator, or UR Agent who is found to have violated the UR rules may be subjected to a penalty of not less than $100 nor more than $1,000 per violation. The Division may also institute a temporary or permanent suspension of the right to perform utilization review services for workers’ compensation claims, if the utilization review agent has established a pattern of violations.

What is utilization review and when is it required?

• Utilization review is the evaluation, by an outside source, of the necessity, appropriateness, efficiency, and quality of medical care services provided to an injured employee.
• Utilization review is required:

1. When the medical necessity of a recommended treatment is disputed or when otherwise required by the workers’ compensation statutes or medical fee schedule (e.g., hospital admissions, physical or occupational therapy, chiropractic care, clinical psychological treatment).