50-6-124 - Utilization review system Pre-admission review Penalties for rendering excessive or inappropriate services Chiropractic and physical therapy services. - Tennessee Statutes

50-6-124. Utilization review system Pre-admission review Penalties for rendering excessive or inappropriate services Chiropractic and physical therapy services.

(a)  The commissioner of labor and workforce development shall establish a system of utilization review of selected outpatient and inpatient health care providers to employees claiming benefits under this chapter, by providers qualified pursuant to law or the utilization review accreditation commission.

(b)  The commissioner shall also establish a system of pre-admission review of all hospital admissions, except for emergency services; however, utilization review pursuant to subsection (a) and this subsection (b) shall begin within one (1) working day of all emergency hospital admissions.

(c)  Pursuant to the commissioner's established system of utilization review, the commissioner may contract with an independent utilization review organization, not owned by or affiliated with any carrier authorized to write workers' compensation insurance in the state, to provide utilization review, including peer review.

(d)  Nothing in this section shall prevent an employer from electing to provide utilization review; however, if the employee, provider or any other party not contractually bound to the employer's utilization review program disagrees with that employer's utilization review, then that employee, provider or other party shall have recourse to the commissioner's utilization review program, as provided for in this section.

(e)  Pursuant to the utilization review conducted by the commissioner, including providing an opportunity for a hearing, any health care provider who is found by the commissioner to have rendered excessive or inappropriate services may be subject to:

     (1)  A forfeiture of the right to payment for those services that are found to be excessive or inappropriate;

     (2)  A civil penalty of not less than one hundred dollars ($100) nor more than one thousand dollars ($1,000); or

     (3)  A temporary or permanent suspension of the right to provide medical care services for workers' compensation claims if the health care provider has established a pattern of violations.

[Acts 1992, ch. 900, § 8; 1996, ch. 944, § 11; 1999, ch. 520, § 41.]