Medical Payment Committee Resolves Work Comp Claim Disputes Between Physicians and Payers
November 13, 2017
Tennessee law provides a process by which healthcare providers can resolve disputes with workers’ compensation carriers over medical bill payments. TCA 50-6-125 gives the workers’ compensation medical payment committee authority to render a decision “on the merits of the dispute.” If the committee determines that the payer acted in bad faith, it can refer it to the state Bureau of Workers’ Compensation for consideration of a civil penalty.
The committee is balanced between provider and insurance industry representatives but almost all dispute resolutions are unanimous. Should there be a tie, the Bureau’s medical director casts the deciding vote.
The process is set forth in the Bureau’s rules at 0800-02-17-.21. Requests for review must be submitted on the Bureau’s one-page Form C-47
with all relevant medical documentation to the committee within a year of the date of service addressed to:
Medical Director of the Workers' Compensation Division
Tennessee Department of Labor and Workforce Development
220 French Landing Drive
Nashville, Tennessee 37243
A copy of all materials submitted to the Bureau must also be submitted to the payer with which the provider has the dispute.
The rule requires that the request for review also contain the following:
Copies of the original and resubmitted bills in dispute which include dates of service, procedure codes, bills for services rendered and any payment received, and an explanation of unusual services or circumstances;
Copies of all explanations of benefit (EOBs);
Supporting documentation and correspondence, if any;
Specific information regarding contact with the carriers; and
A verified or declared written medical report signed by the physician and all pertinent medical records.
Any request that is untimely submitted or does not include all required forms and documentation may not be reviewed. The committee will interpret the Medical Fee Schedule Rules or other applicable rules.
The Bureau’s legal staff clarified the committee’s authority in October 2017. Since the committee is advisory in nature and has authority to interpret the rules and fee schedules, it can make rulings based on those interpretations that may go beyond what a disputant asks. In a recent case, the committee recommended a payment award higher than what the provider had computed he was entitled. Bottom line, a committee payment recommendation is not like baseball arbitration; it does not have to choose between the calculations submitted by the provider and payer. It can make what it believes is the proper interpretation based on the documentation presented.
Following is an example of the types of disputes the committee reviews: A workers’ compensation payer had a payment policy that it would not pay for more than three (3) urine drug screens (UDS) per patient per year. A pain management physician submitted a claim to the payer for a fourth UDS for a chronic pain patient. The claim was denied so the physician asked for review of the claim denial. The committee considered the state’s chronic pain guidelines, which allow physicians to order three or four UDSs a year if extenuating circumstances are documented by the treating physician. Suspected abuse of controlled medication is considered an extenuating circumstance, according to the guidelines. The committee recommended that the physician be reimbursed by the payer for the fourth UDS.
Physicians treating workers’ compensation patients should consider using the medical payment committee to resolve payment disputes when they feel strongly they are in the right.