Tenn. Comp. R. & Regs. 0800-02-19-.06 - PENALTIES FOR VIOLATIONS OF FEE SCHEDULES

(1) Except when a waiver is granted by the Bureau, providers shall not accept and employers shall not pay any amount for health care services provided for the treatment of a covered injury or illness or for any other services encompassed within the Rules for Medical Payments, Medical Fee Schedule Rules or the Inpatient Hospital Fee Schedule Rules, when that amount exceeds the maximum allowable payment established by these Rules. Any provider accepting and any employer paying an amount in excess of the Rules shall be in violation of the Rules and may, at the Administrator's discretion, be subject to civil penalties of up to one thousand dollars ($1,000) per violation for each violation, which may be assessed severally against the provider accepting such fee and the employer paying the excessive fee, whenever a pattern or practice of such activity is found. At the discretion of the Administrator, the Administrator's Designee, or an agency member appointed by the Administrator, such provider may also be reported to the appropriate certifying board and may be subject to exclusion from participating in providing care under the Law. Other violations of the Rules for Medical Payments, Medical Fee Schedule Rules, or the Inpatient Hospital Fee Schedule Rules may subject the alleged violator(s) to a civil penalty of not less than fifty dollars ($50) nor more than five thousand dollars ($5,000) per violation, at the discretion of the Administrator, the Administrator's Designee, or an agency member appointed by the Administrator.

(2) Any provider reimbursed or carrier paying an amount which is in excess of these Rules shall have a period of one hundred eighty (180) calendar days from the time of receipt/payment of such excessive payment in which to refund/recover the overpayment amount. Overpayments refunded/recovered within this time period shall not constitute a violation under these Rules.

(3) A provider, employer or carrier found to be in violation of these Rules, whether a civil penalty is assessed or not, may request a contested case hearing by requesting such hearing in writing within fifteen (15) calendar days of issuance of a Notice of Violation and, if applicable, the notice of assessment of civil penalties. All rights, duties, obligations, and procedures applicable under the Uniform Administrative Procedures Act, Tenn. Code Ann. §§ 4-5-101 et seq., are applicable under these Rules, including, but not limited to, the right to judicial review of any final departmental decision.

(4) The request for a hearing shall be made to the Bureau in writing by an employer, carrier or provider which has been notified of its violation of these Rules, and if applicable, assessed a civil penalty.

(5) Any request for a hearing shall be filed with the Bureau within fifteen (15) calendar days of the date of issuance of the Notice of Violation and, if applicable, of civil penalty. Failure to file a request for a hearing within fifteen (15) calendar days of the date of issuance of a Notice of Violation shall result in the decision of the Administrator, Administrator's Designee, or an agency member appointed by the Administrator becoming a final order and not subject to further review.

(6) The Administrator or the Administrator's Designee, shall have the authority to hear the matter as a contested case and determine if any civil penalty assessed should have been assessed. All procedural aspects set forth in the Bureau's Penalty Rules, Chapter 0800-02-13, shall apply and be followed in any such contested case hearing.

(7) Upon receipt of a timely filed request for a hearing, the Administrator shall issue a Notice of Hearing to all interested parties.

Notes

Tenn. Comp. R. & Regs. 0800-02-19-.06

Public necessity rule filed June 5, 2005; effective through November 27, 2005. Public necessity rule filed November 16, 2005; effective through April 30, 2006. Original rule filed February 3, 2006; effective April 19, 2006. Amendment filed June 12, 2009; effective August 26, 2009. Amendment filed December 26, 2013; effective March 26, 2014. Amendments filed November 27, 2017; effective February 25, 2018. Administrative changes made to this chapter on September 10, 2019; "Tennessee Workers' Compensation Act" or "Act" references were changed to "Tennessee Workers' Compensation Law" or "Law." Amendments filed June 27, 2023; effective 9/25/2023.

Authority: T.C.A. §§ 50-6-102, 50-6-125, 50-6-128, 50-6-204, 50-6-205 (Repl. 2005), 50-6-233, and Public Chapters 282 & 289 (2013).