Public Chapter 289 (2013) and Tennessee Code Annotated § 50-6-204 (j)(5)authorize an employer to use utilization review to determine the medical necessity of a treatment recommended by an authorized treating physician, and, in instances required by the workers’ compensation statutes or the medical fee schedule.

Utilization review is required in the form of pre-admission review for all inpatient hospital admissions, and concurrent review should be done after discharge. Emergency admissions require utilization review within one business day of the admission. Utilization review is required on chiropractic, physical and occupational services after twelve visits. In order to facilitate expedited utilization review, whenever a physician orders physical therapy or occupational therapy the physician should include the diagnosis on the prescription for physical therapy or occupational therapy. Utilization review is required for psychological treatment services in excess of fifteen (15) visits.

Pursuant to Tennessee Code Annotated § 50-6-204(j)(5) and Rule 0800-02-06-.07 (2) (c), the Division is authorized to impose a fee for the administration of the utilization review appeal process. Accordingly, the Workers’ Compensation Division, or their contractor, Eckman/Freeman & Associates, will collect a fee not to exceed $250 for each review conducted. After the utilization review appeal is completed, an invoice will  be submitted to the employer, or their workers’ compensation insurance carrier, for payment. The fee shall be paid by the employer, or their workers’ compensation insurance carrier, within thirty (30) calendar days of the completion of the utilization review appeal. If the fee is not paid within the time frame, then a 10% interest payment shall accrue for every thirty (30) calendar days that the fee remains unpaid.

The Workers’ Compensation Division, or their contractor, Eckman/Freeman & Associates, will provide notice to the employer’s workers’ compensation insurance carrier’s adjuster whenever it receives an appeal of a utilization review decision rendered pursuant to the statute. If the carrier decides to rescind the original utilization review decision, the carrier must inform the Workers’ Compensation Division, or their contractor, Eckman/Freeman & Associates, of its decision within two (2) business days of the date the Division, or their contractor, notified the carrier of the utilization review appeal to avoid assessment of the fee. In order to avoid the fee, information that the utilization review decision has been rescinded must be provided to the entity– meaning either the Division or Eckman-Freeman–that sent the carrier notice of the utilization review appeal.

The Notice of Appeal Rights for a Utilization Review Denial (Form-C35A) was updated in December of 2010. Please note that any older versions of the Form-C35A will not be accepted and will be returned to the carrier and/or their utilization review company as invalid. The carrier and/or their utilization review company will be required to resubmit the correct version of the form.

This information was generated by the Tennessee Department of Labor and the original source can be found here http://www.tn.gov/labor-wfd/wcomp/forms/UR%20Appeal%20Fee%20Notice.pdf

The Tennessee Department of Labor has been expanding efforts to uncover employer fraud within the construction industry.

The efforts, aided by recent legislation, will help identify employers who are paying workers under the table, intentionally misclassifying workers as independent contractors, and who are failing to report all wages paid.

The state Department of Labor & Workforce Development said a Nashville drywall firm accused of lying to an insurance company about how many employees were on its payroll was first to pay $300,000 in a settlement.

Officials said the fraud is typically used to avoid paying workers’ compensation and unemployment insurance tax premiums. It also gives deceptive employers an unfair competitive advantage over law-abiding firms, they said.

Part of the effort includes the hiring of additional investigators to detect the fraud. Since legislation went into effect in July 2013, three investigators have been hired.

The agency is also buying new fraud detection software and plans a public awareness campaign that will include a website and a phone line at 1-800-332-2667 for citizens to report a business suspected of misclassifying its workers.

This information was produced by the Insurance Journal and the original source of the information can be found here http://www.insurancejournal.com/news/southeast/2014/06/06/331240.htm

The Medical Impairment Rating (MIR) Registry is a Division of Workers’ Compensation-maintained listing of qualified and approved physicians who are specially trained to conduct impairment rating medical evaluations and who have applied to serve on the Registry.  The program is designed to assist parties in settling a workers’ compensation claim when the only item being disputed is the impairment rating.  The program provides the names of physicians, listed on the Registry, who are specifically trained in the techniques of performing impairment rating evaluations on the body part(s) involved in the workers’ compensation claim.  The physicians whose names are provided will be objective and impartial since they will not have been involved in the claim whatsoever.  The rating produced by the physician selected by the parties is utilized to help determine any Permanent Disability Benefits due in the matter. Before the parties can request a MIR evaluation, there must be a dispute about the impairment rating.  A dispute occurs when:

• There are competing impairment ratings issued by different physicians, and the parties disagree as to which rating is correct (dueling doctors), or
• The treating physician has placed permanent restrictions on the claimant, but has issued a rating of “zero,” or states that there is “no permanent impairment.”
• To request the MIR evaluation, one of the parties must submit the Application for a Medical Impairment Rating (MIR) form to the division.

The Program is designed to increase the number of cases being settled outside the courts.  It is quicker, less expensive and adds consistency and predictability to the system when compared to having the issue resolved in court. For additional information about this topic, please call the Tennessee Department of Labor at 615-532-4812 or 1-800-332-2667. IMPORTANT NOTES:

• The program is available only for dates of injuries on/after July 1, 2005.
• An MIR evaluation may be requested by either party.  Regardless of which party requests it, the cost of the evaluation is borne by the employer.
• To help eliminate some of the unproductive negotiations and unnecessary lawsuits, opinions that physicians issue in MIR evaluations are considered, by statute, to be “accurate” and can be overcome only by clear and convincing evidence to the contrary.
• The report provided by the MIR physician will provide only the impairment rating.  It will not address causation, apportionment, job restrictions or modifications, or the appropriateness of treatment.
• Injuries occurring on or after January 1, 2008 must be rated by The AMA Guides to the Evaluation of Permanent Impairment, 6th Edition.
• Injuries occurring prior to January 1, 2008 must be rated by the applicable version of the AMA Guides, as determined by the Tennessee Workers’ Compensation Act.

The Penalty Program investigates and assesses penalties for violations of the Tennessee Workers’ Compensation Act other than those covered by the Uninsured Employers Fund (UEF) and the Employee Misclassification Education and Enforcement Fund (EMEEF).   The Program enforces several penalties, including:

• A 25% penalty for failure to pay or to timely pay temporary disability benefits; (If assessed, this penalty goes to the injured employee not to the Division.)
• A $10,000+ penalty for failure to timely comply with a Specialist’s or Administrator’s Designee’s order; and
• A penalty for an insurance company’s or self-insured employer’s failure to timely file claims forms; (Timely claims forms are important to the Division as the forms supply important claims information to the legislature for its consideration regarding changes to the Workers’ Compensation Act.)
• Other various penalties.

Click here for a summary of workers’ compensation penalties.

For additional information about this topic, please call  the Tennessee Department of Labor at 615-532-4812 or 1-800-332-2667.

IMPORTANT NOTES:

• A 25% penalty for failure to pay or to failure to timely pay temporary disability benefits assessed by the department is payable to the injured employee.  All other penalties collected go into the Second Injury Fund.
• To be considered timely and to avoid the $10,000+ penalty, employers or their insurance carriers are required to comply with the Benefit Review Program’s Attorney Specialist’s Order within fifteen (15) calendar days of its receipt, unless a request for Administrative Review is filed.
  • If Administrative Review is requested, the obligation to comply with the Order is suspended until the Administrative Review is resolved.
• To be considered timely and to avoid the $10,000+ penalty, Employers or their insurance carriers are required to comply with the Administrative Review Program’s Administrator’s Designee’s Order within ten (10) calendar days of receipt.
• Continued failure to comply with an Order 21 days after its receipt shall result in an additional penalty of $1,000.00 per day.
• When determining whether or not a penalty is appropriate, there is a “strict liability” standard applied.  Either the employer or their insurance carrier timely complied with the Order, or it didn’t.