What’s Happening?

On May 27, Tennessee’s Bureau of Workers’ Compensation (BWC) issued an email bulletin that, among other things, provides updated information on the BWC’s REWARD program. This includes the upcoming Certified Physician Program and associated training that will be offered to those physicians who wish to become certified.

Physicians who complete the training would receive CME credits, be listed on the BWC’s website as a “Certified Physician” and be entitled to enhanced fees and reduced UR requirements. The training will be offered as a self-paced, online course, with an exam to test the physician’s familiarity with the material.

The program is expected to be ready sometime in 2022.

Because there is very little information available at this point, there hasn’t been much discussion of this program in the industry news. I’m sure that we’ll learn more as we get closer to a roll-out date. However, even with as little information as we have at this point, I’m tentatively excited and here’s the reasons why:

1. The obvious: it could encourage more healthcare providers to treat workers’ compensation patients.

It goes without saying that provider participation is always a concern in workers’ compensation, especially when it comes to rural areas and ensuring that patients have access to providers in different specialties. Because providers who treat work comp patients have so many additional hurdles to clear in order to get paid (compensability/relatedness issues, pre-authorization requirements, retrospective utilization review, reporting and billing requirements, etc.), having a successful work comp practice requires some level of expertise in the Tennessee workers’ compensation system. Building that expertise takes time, something that providers have in short supply.

Even with fee schedule reimbursement rates meeting or exceeding the rates offered by Medicare, some providers may feel that those rates alone aren’t enough to justify the additional headache – or the risk of not getting paid anything after battling through the UR and appeal process.

If you want more providers to participate in a system, make it worth their time to do so. You do this by:

• increasing the reward;
• reducing the risk;
• reducing the time/financial cost to build the necessary expertise.

It sounds like this program is intended to do all three.

2. It could decrease the administrative costs associated with Utilization Review (UR).

The bulletin wasn’t specific about the “reduced UR requirements” that would apply to physicians who complete the program and become certified, but, presumably, certain treatments by those physicians would be subject to comparatively limited UR. That’s a great incentive for physicians, but there’s a hidden benefit for payers.

When physicians treat in accordance with the guidelines, payers don’t have to spend money on UR. If this program teaches new or new-to-work-comp physicians how to document compliance with the applicable treatment guidelines, that would reduce the need for UR. Less UR means lower claim admin costs, fewer complaints from injured workers and providers, and less risk of investigation and penalties by the BWC because of errors in the UR process.

There will certainly be instances where treatment has to deviate from the guidelines. But if the physician is documenting (1) how the guidelines are not applicable, or (2) how the circumstances surrounding treatment of this patient require deviation from the guidelines, it becomes much more likely that the treatment can be approved at the initial review stage (often performed by a nurse) rather than escalating to a more costly review by a physician.

In other words, where UR does occur, it will likely be cheaper, with only those treatments that are clearly not medically necessary being escalated to the more expensive physician review.

3. It protects healthcare providers who do the right thing.

This is not a first for the BWC. Tennessee’s utilization review system has been designed to protect providers from denial of payment where there is little to no question that the treatment is medically necessary. This is true not just with respect to more common things that we see in other states – like adopting treatment guidelines that a provider can use to establish medical necessity or adopting a formulary with a list of a drugs that aren’t subject to pre-authorization – but also with respect to practical details like ensuring that a pharmacy that dispenses a “Y” drug in good faith doesn’t get punished by a subsequent UR denial. The rule doesn’t protect pharmacies that dispense the drug after a UR denial has been issued, but, at that point, the pharmacy should be able to determine that the drug has been denied.

I don’t think that UR is going away anytime soon. But between Tennessee’s increased penalties for those who abuse the UR process (up to $5,000 per violation for most infractions) that protect existing providers who play by the rules, and this new Certified Physician Program, the risk of an improper UR denial harming a physician’s practice will continue to diminish.

What’s Next?

Expect to hear more about this program in the coming months. It’s a powerful idea, but the details will be crucial to its success. That said, the BWC likely already has a fairly solid idea of what it’s willing to offer those physicians who become certified. Like most agencies, the BWC is hesitant to make promises about future policy. If they’re currently promoting this program as offering “enhanced fees,” and “reduced UR requirements,” that’s not a promise they’ve made lightly.

If done well, this could change the landscape of medical management of Tennessee claims and maybe even provide a model for other states.

Please subscribe to this blog for updates on this and other changes in workers’ compensation. There’s always something happening and it’s my job – and passion – to stay on top of it all.

David Price, Director of Government Affairs, Preferred Medical