Hughes & Coleman | Injury Law Blog

The insurance company has the right to send any recommended treatment to utilization review.  Utilization review is the evaluation, by an outside source, of the necessity, appropriateness, efficiency, and quality of medical care services provided to an injured employee.

The adjuster has three business days after being notified of the recommended treatment to authorize the treatment or send the recommendation to its utilization review agent.  The recommended treatment can only be denied by a physician who has an active TN-license, who is board-certified and in the same or similar general specialty as the authorized treating physician. 

Utilization has seven business days to make a decision on the recommended treatment.  All parties should be notified of the decision. If utilization does not have all of the necessary information needed to render a determination, then they shall request additional information in writing from the authorized treating physician, who shall comply with the request within five business days of receipt of the written request. The seven business days are tolled until utilization receives the information or until the five business day timeframe expires, whichever occurs first. The decision from utilization shall only address medical necessity.  It shall not address causation and/or compensability.  An approval of the treatment by the utilization review agent is final and not subject to appeal.

If you receive a denial, then you, your attorney or your treating physician has 30 calendar days from receipt of the denial to appeal the decision to the Department of Labor.  After a complete medical record is received by the Department of Labor, the Medical Director will determine if he agrees or disagrees with the decision.  If he disagrees with the decision, an order for the treatment as recommended by the authorized treating physician will be issued.  If he agrees with the decision, then the denial will be upheld.

For more information on being injured on the job in Kentucky or Tennessee visit http://www.hughesandcoleman.com/workers-compensation-lawyer.php.

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The purpose of the nurse case manager was to help coordinate medical care for the employee with the treating doctors/facilities.  The insurance company pays for the nurse case manager.

If there is a nurse case manager on your case, then you should ask him/her to wait outside of the room while the doctor examines you.  Once the doctor has finished his exam, then the nurse case manager can come in while the doctor is discussing the findings. 

Remember, the nurse case manager can assist with scheduling your appointments but is not your “friend”.  You should not be discussing your personal life with the nurse case manager.

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The Tennessee Department of Labor and Workforce Development’s Workers’ Compensation Division is available for questions.  They can be contacted at 1-800-332-COMP (2667).  You can also visit their website at www.tn.gov/labor-wfd/wcomp.html. 

If you have a hearing impairment you may use TN Relay Service 711; 1-866-503-0263.

For more information on a work injury in Tennessee visit http://www.hughesandcoleman.com/workers-compensation-lawyer.php

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The new bill authorizes a physician to order pain management for an employee determined to have persisting pain due to their work injury.  The employee is still entitled to a panel of physicians if the treating physician makes a referral for pain management treatment.  The injured employee will be required to sign a formal agreement with the physician acknowledging the conditions under which the injured or disabled employee may continue to be prescribed such controlled substances and agreeing to comply with such conditions.   If the employee violates the agreement, the employer may terminate the pain management.  If this occurs, the employee has the right to file a request for assistance with the department of labor or petition the court for further treatment.

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Many questions arise when you are injured on the job. One being, Can I be fired?

No, an employer cannot fire you for reporting a work injury.  If you are fired for reporting a work injury, then you may have a wrongful termination claim against your employer.

For more information on work related injuries and steps to take when this happens visit http://www.hughesandcoleman.com/workers-compensation-lawyer.php.

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