News
BILL SUMMARY FOR TENNESSEE *SB0445 / HB0454
Current Tennessee law authorizes the commissioner of labor and workforce development, in consultation with the medical care and cost containment committee and the advisory council on workers' compensation, to establish by rule a comprehensive medical fee schedule for fees of physicians and surgeons, hospitals, prescription drugs, and ancillary services provided by other health care facilities and providers charged for provision of workers' compensation-related treatment. The comprehensive medical fee schedule does not prohibit an employer, trust or pool, or insurer from negotiating lower fees in its own medical fee agreements.
This bill, now law, requires that any fees paid for medical services furnished in Tennessee on or after January 1, 2008 that are lower than the fees provided in the comprehensive medical fee schedule be made pursuant only to a contract between the health care provider and the employer, trust, pool, or insurer. This law prohibits the assignment of negotiated rates for workers' compensation services to any other party than the employer, trust, pool, or insurer who signed the contract or agreement. If there is not an existing contract, the law requires payments to be the reimbursement rates established in the comprehensive medical fee schedule.
PRIME HEALTH AND TENNESSEE SENATE BILL 445
This new Tennessee law does not currently have any rules or regulations attached to it. Prime Health Services is directly contracted in the state of Tennessee. We have coverage border to border, and offer a full functioning PPO network for workers’ compensation. Our contracts are clearly laid out to specify workers’ compensation. Thus, at this time, we believe we are in full compliance with this new law.
ON MAY 21, 2007, THE SENATE ADOPTED AMENDMENT #1 AND PASSED SENATE BILL 445, AS AMENDED.
AMENDMENT #1 rewrites this bill to impose various requirements, applicable upon entering or renewing a provider contract, on every contracting agent that sells, leases, assigns, transfers, or conveys its list of contracted healthcare providers and their contracted reimbursement rates. This amendment defines "contracting agent" as any person who is in direct privity of contract with a medical provider to reimburse the medical provider for medical services provided to an injured worker pursuant to the Workers' Compensation Law at rates other than those provided under the workers' compensation medical fee schedule. The requirements imposed on such agents, which take effect on January 1, 2008, are as follows:
(1) Disclose to the provider whether the list of contracted providers may be sold, leased, transferred, or conveyed to other payors or agents including workers' compensation insurers or self insureds;
(2) Disclose whether payors to which the list of contracted providers may be sold, leased, transferred, or conveyed may be permitted to pay a provider's contracted rate if less than the workers' compensation fee schedule;
(3) Allow providers, upon the initial signing or renewal of a provider contract, to decline to participate in networks solely to serve workers' compensation payors that are sold, leased, transferred, or conveyed to workers' compensation payors; and
(4) Maintain a Web page that contains a complete listing of customers to whom the network is sold, leased, transferred or conveyed that is accessible to all contracted providers and updated at least twice a year and maintain a toll-free telephone number accessible to all contracted providers whereby providers may access workers compensation payor summary information and a list of lessees of the network.
This amendment also adds the following requirements for workers' compensation payors, also beginning on January 1, 2008:
(1) The workers' compensation payor's explanation of benefits or explanation of review must identify the name of the network that has a written agreement signed by the provider whereby the workers' compensation payor is entitled, directly or indirectly to pay a preferred rate for the services rendered; and
(2) A workers' compensation payor must demonstrate that it is entitled to pay a contracted rate within 30 business days of receipt of a written request from a provider who has received a claim payment from the workers' compensation payor. The provider must include in the request a statement explaining why the payment is not at the correct contracted rate for the services provided. The failure of the provider to include a statement will relieve the workers' compensation payor from the responsibility of demonstrating that it was entitled to pay the disputed contracted rate. A workers' compensation payor will be deemed to have demonstrated that it is entitled to pay a contracted rate if it identifies the contracting agent who has contracted with the medical provider to pay the reimbursement at the contracted rate.
For more information regarding this law contact: info@primehealthservices.com.