Utilization Review System — Pre-Admission Review — Penalties for Rendering Excessive or Inappropriate Services — Legislative Intent. [Applicable to Injuries Occurring Prior to July 1, 2014.]

1. Law
2. Tennessee Code
3. Employer and Employee
4. Workers' Compensation Law
5. General Provisions
6. Utilization Review System — Pre-Admission Review — Penalties for Rendering Excessive or Inappropriate Services — Legislative Intent. [Applicable to Injuries Occurring Prior to July 1, 2014.]

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. It is the intent of the general assembly to ensure the availability of quality medical care services for injured and disabled employees and to manage medical costs in workers' compensation matters by eradicating prescription drug abuse through the employment of the system established by subsection (a) to review any healthcare provider prescribing one (1) or more Schedule II, III, or IV controlled substances for pain management to an injured or disabled employee for a period of time exceeding ninety (90) days from the initial prescription of such controlled substances.

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