Case Management and Utilization Review — Use of Hmos and Ppos — Legislative Intent — Claims by Health Care Providers

  1. Law
  2. Tennessee Code
  3. Employer and Employee
  4. Workers' Compensation Law
  5. General Provisions
  6. Case Management and Utilization Review — Use of Hmos and Ppos — Legislative Intent — Claims by Health Care Providers

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    1. It is the intent of the general assembly that quality medical care services shall be available to injured and disabled employees. It is also the legislative intent to control increasing medical costs in workers' compensation matters by establishing cost control mechanisms to ensure cost-effective delivery of medical care services by employing a program of medical case management and a program to review the utilization and quality of medical care services.
    2. In order to assure that in workers' compensation cases quality medical care is rendered and to control medical care costs, an employer is authorized to use, but is not required to use, health maintenance organizations (HMOs) and preferred provider organizations (PPOs). An HMO or PPO may contract with medical care providers as permitted by law. The contracts are authorized to use, but are not limited to the use of, the following managed care methodologies:
      1. Medical bill review;
      2. Establishment of medical practice guidelines;
      3. Case management, subject to § 50-6-123;
      4. Utilization review, subject to § 50-6-124; and
      5. Peer review programs.
    3. Section 50-6-204(a)(3), relative to medical care, shall apply to any managed care methodology employed pursuant to this section. For the purposes of § 50-6-204(a)(3), physicians and surgeons in the same HMO or PPO are considered to be associated in practice together if they share a common employer for purposes of their clinical practice, or are associated together in a group practice.
  2. A health care provider shall not pursue a private claim against a workers' compensation claimant for all or part of the costs of health care services provided to the claimant by the provider unless:
    1. The injury is finally adjudicated not to be compensable under this chapter;
    2. The physician or surgeon, as provided in § 50-6-204, who was not authorized by the employer at the time the services were rendered, knew that the physician or surgeon was not an authorized physician or surgeon; or
    3. The employee knew that the physician or surgeon was not an authorized physician or surgeon; provided, that subdivision (b)(2) and this subdivision (b)(3) do not apply to emergency care.
  3. [Deleted by 2013 amendment, effective July 1, 2014.]


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