Meeting Minutes

May 20, 2025 via Teams

Tennessee Room, 220 French Landing Drive, Nashville, TN 37243

Members:

• David Tutor, MD, Occupational Medicine        
• Rob Behnke, Cracker Barrel
• Carina Sloat, RN, CCM, Travelers
• Richard L. Cole, DC, DACNB, DAAPM, FICCN, FICC(H)
• John Brophy, MD, Neurosurgery
• James G. Kyser, MD, Psychiatry
• Jeff Hazlewood, MD, PM&R, Pain Management
• Lisa Bellner, MD, PM&R Pain Management
• Veatrice Storey, Zurich Insurance
• Ginny Howard, Arch Insurance
• Cerisia Cummings, DO, Bridgestone

Staff:

• Troy Haley, Administrator, BWC
• Robert Snyder, MD, Medical Director, BWC
• James Talmage, MD, Asst. Medical Director, BWC
• J. Wills Oglesby, MD, Asst. Medical Director, BWC
• Amanda Terry, BWC
• Jay Blaisdell, BWC
• Suzy Douglas, RN, BWC
• Lacy Conner, BWC
• Marshay Jones, BWC
• Jennifer Schneider, BWC
• Maria Trotter, BWC
• Anne Zimmerman, BWC
• Kyle Jones, BWC
• Suzanne Gaines, BWC
• Mark Finks, BWC

Guests:

• Tommy Castleberry, Concentra
• Troy Prevot, ODG by MCG
• Brian Allen, Enlyte
• Adam Fowler, My Matrixx
• Tiffany Grzybowski, HealtheSystems
• Adam Jaynes, MGR
• Faith Parrish, VUMC
• Stacy Barfield, Erie Insurance
• Larry Brinton, Accuro Solutions
• Yarnell Beatty, TMA
• Sandy Shtab, HealtheSystems
• Jess Bateman
• Alexa Cameron, Erie Insurance
• Peggy Hohertz, Enlyte
• Tanya

In Person:

Carina Sloat, Travelers

David Tutor, MD, ETUC        

Cerisia Cummings, DO, Bridgestone

John Brophy, MD, Neurosurgery

By Telephone:

Tommy Castleberry, Concentra

Veatrice Storey, Zurich Insurance

J. Wills Oglesby, MD, Asst. Medical Director, BWC

Virtual Option:

The meeting will be held in the BWC Large Conference Room with telephone and virtual options available. The use of the virtual platform is a benefit to the public, allowing participation of out-of-state stakeholders and others interested in the subjects of this meeting.   It is necessary for establishment of a quorum that the members have the virtual option available.  The committee rules provide for the members to be counted as present for the determination of a quorum (see rule 0800-02-23-.04 (2-3)).

Call to Order

The meeting was called to order at 1:06 PM by the Chair, Dr. Tutor. 

Introductions were made.

Quorum

Ms. Terry took the role, and a quorum was confirmed as present (1/3 of the members needed, 11/18 members present).

Approval of Minutes

Dr. Tutor called for approval of the minutes for the February 4^th meeting.   Dr. Cole motioned and Mr. Behnke seconded.   

The minutes were passed as written.

Any remaining Conflict of Interest forms need to be turned in.

Old Business

Formulary Updates:

The updates to the drug formulary that became effective 5/1/2025 are posted to the website.  Dr. Snyder reviewed the updates, and they are free to anyone for download. 

Dr. Oglesby motioned to accept the update as written, and Dr. Cummings seconded.

The committee voted to accept the Drug Formulary update.

 

ODG Updates:

Dr. Talmage and Dr. Brophy led the discussion of updates.

Dr. Brophy referred to the discussion of December 2024 with ODG about the problem with therapies as it relates to lumbar cervical radiculopathy, specifically the 3-month timeline to have surgical treatment, and the micromanagement regarding therapy in general.  For example, in this condition 6 visits for 3 weeks, but without any background about the exam results or mechanism of injury.    The next is the lumbar treatment of the spine, 12 visits over 10 weeks.

Is that congenital, degenerative, due to a ruptured disc?

The more appropriate way to handle therapy would be through accurate diagnosis by the treating physician and then determining the length of treatment based on the positive response to treatment.  Initially, ODG was beneficial by limiting the number because there is a bigger problem with patients wanting to do therapy indefinitely rather than doing too short a period.  Those were the suggestions for December.

There were also recommendations regarding lumbar and cervical radiculopathy issues.  Recommendation: 1. regarding therapy was where no further progress is made to an adequate trial of physical therapy.  2. In lieu of the treatment with anti-inflammatories and steroids for 3 months should be: “failure of a response to one or more oral NSAIDs or steroids if not contraindicated”. 

On 2/14/2025, an email from Mr. Prevot mentions that there is evidence that strongly recommends a trial of physical therapy.  Although there is some variability in the length of conservative treatment.

There was a paper 30 years ago that says lumbar radiculopathy is 60% of patients are better in a year, and 82% in 4 years, and 91% in 10 years no matter what if any treatment is given.  It gets better with time but waiting 3 to 6 months to get back to work is problematic. 

Therapy is not the treatment for acute radiculopathy.  Elapsed time is assumed by the patients and the therapist that the therapy is working.  It’s decreased activity time and anti-inflammatory steroids that help the most. 

Provide the patient with every opportunity to avoid invasive procedures with inherent risks.   Physicians routinely do 12 weeks of conservative management, but it is not all therapy.  It is a few weeks of therapy but if it doesn’t work, what else have you got?  Some injections?  MRI shows it’s a target?  The absolute last resort is surgery when they decide there is no choice.  The patients expect to get back to work and are asking for surgery, the physicians are not suggesting it.

There is also the group that comes into the clinic in wheelchairs, unable to stand or walk.   They have been to the ER twice in 2 weeks, getting steroids and narcotics.  Diagnostic studies reveal a ruptured disc.    With the ODG guidelines saying 3 months in every other location is going to give a UR adjuster opportunity to avoid treating the patient who needs to get treatment for their acute ruptured disc. 

ODG has a statement that if worsening symptoms provide an option, the treatment can be advanced.  But with the 12 weeks in many locations, from experience with commercial insurance, the UR people say their hands are tied and they must give the mandatory length of time and X amount of therapy even though there is no proven benefit that therapy works better than other things.  The therapy is $100.00 a visit and the patient loses half a day of rest.  If it is not working, why pursue it?   The time limit is the major problem with using ODG moving forward and all the ways it limits treatment options for both cervical and lumbar radiculopathy.

The stipulation of six visits of physical therapy are reasonable, but shouldn’t there be some improvement?

Most of the chiropractors say a reasonable trial for them is 10 visits, but why continue if it is not working? 

Dr. Brophy identified those under cervical and lumbar radiculopathy.   There are many other places in the physical therapy where they say physical therapy for 3 months.  The provider is restricted to a time frame or a certain number of visits.  This does not make sense if it is not helping, or if it is contraindicated.  Why limit it when the wording that was sent in is “an adequate trial of physical therapy is at the discretion of the physician”?   If the patient is making progress, they want to continue, and the physician will agree.  If there is a lack of progress, then putting a time frame or number of visits tie the hands of patient and physician to the point that it is detrimental to the overall goals which are return to work and return to health.

Dr. Cole agreed that they should be able to document within 10 visits some objective improvement.  If there is no objective improvement within 10 visits, do something different.

Mr. Prevot said that there were a lot of places under the guidelines under physical therapy for the low back.  It gives some guidelines on the number of visits over time.  The idea is that if you don’t see functional improvement, that’s generally instead of objective improvement.  Functional improvement is not always objective, and maybe the patient is not getting better subjectively, too.  The idea of physical therapy and the way the editors have expressed it to the support team is the idea that these are a guideline.  For example, lumbar strain under physical therapy for low back, 10 visits over 8 weeks would be the optimal treatment recommended.  That’s included so that the methodology is documented in some of the materials that are on the website.  Quite a few lumbar related conditions are not all grouped into 3 months.  The physical therapy recommendations can go back to the editors for another look.

Dr. Talmage said that Utah workers’ comp has a form that the therapist fills out every week.   It documents objective improvement that occurred that week or the physical therapy stops if there is no improvement.  Why keep doing it?

He agreed with Dr. Brophy that there is no literature that says therapy is effective treatment for acute cervical or lumbar radiculopathy. It is probably time, and therapy may be a way to keep the patient occupied while waiting to see if spontaneous improvement in disc resorption occurs with time. Dr. Brophy is right that physicians ought to have the say that if a patient is not improving, then having an arbitrary 3 months of therapy for a lumbar fusion makes no sense if it is not helping.

Mr. Prevot asked if that wouldn’t be more of a regulatory process than to be put into a guideline when it comes to the use of a form?   Dr. Talmage answered that the form would have to be regulatory, but the principle is if you cannot document improvement from the physical therapy or chiropractic records, then it’s time to try something else.    

Mr. Prevot emphasized that the guidelines are not intended to steer the patient towards surgery.  Would there be any change in the 12-week issue?   Mr. Prevot agreed that it needs to be cleared up, and he would bring it back to the editors.   The guidelines are modified based on the committee’s reaction to the 8 specific guidelines.   

The next update is for discography.  Dr. Talmage presented some background.  Tennessee adopted the ODG as presumptively correct for utilization review treatment in July of 2024.  ODG came out with a new set of criteria and guidelines for several topics.  The Medical Advisory Committee refused to recommend that the administrator adopt those 7/2024 updates and provided some criticism.  In 11/2024, there was a second set of revised criteria and guidelines that did not please the committee.  On April 4^th there is a third set, so in nine months there have been 3 sets of criteria for the same diagnostic topics.  Washington State and ACOEM are alternatives to be looked at.

Washington State uses the Canadian workers’ comp system.  In that system, the state government is workers’ comp and there is no private insurer.  The legislator of Washington State took 3 populations: workers’ comp, Medicaid, and state government employees.   They put them all together and created an evidence review process to determine coverage decisions.  If they pay for it, it is Medicaid, state employees, workers’ comp.  If they don’t pay, they don’t pay for any of those 3 populations. 

This is the 3^rd set of discography criteria in the last 9 months.  It starts with not recommended, generally, and then gives criteria for when discography would be appropriate.  Discography is the injection of X-ray dye into the middle of the disc.  You are looking for the response:  Does the injection and pressurization of the disc create the patient’s pain or worsen the patient’s pain?  Exact reproduction of pain.

The criteria proposed in April are the disc is highly suspected of being the source of the pain and that imaging can’t clearly confirm that imaging is the source of the pain.  There are multiple publications by international organizations and consensus groups that say there is no test capable of determining that the disc is the source of pain.  Yet, the criteria are the disc is highly suspected of being the source of pain.

If there is a positive discogram, the answer in the proponents’ mind is a lumbar fusion at that disc level.  If you skip the discography ODG criteria and go to lumbar fusion criteria, the last sentence on the third or fourth page says not recommended for discogenic back pain.  So, they provide criteria for doing a test and if there is a positive test, nothing can be done surgically.  It makes no sense.  Washington State says discography is not covered, and ACOM guidelines say discography is not recommended.

The new ODG says it might be considered if the disc is suspected of being the source of pain.   It has been shown that discography raises the pressure in the disc that is being injected, and raises pressure in the adjacent disc.    That is the reason you could have reproduction of the patient’s pain and yet identify the wrong level.

Eugene Carragee did a series that showed when discography is done, for a positive discogram, you must have a normal disc that you inject and get normal pictures and no pain response.  If you follow those people for 10 years, what was a normal disc gets operated for a disc herniation and the disc degenerates much more quickly than the people who were candidates but didn’t get a discography. Therefore, adjacent discs are likely harmed by discography.  It’s a test that harms some people and has no benefit if you get a positive result. 

A study by Anderson in Ohio workers’ compensation says of people who were thought to be fusion candidates, if they had discography the outcomes were worse with their fusion than if they didn’t have discography and but only had the fusion.

This is the third set of criteria for discography and lumbar fusion by the same organization in 9 months.  It makes it difficult with utilization review; which set of guidelines should be used?

There is a sacroiliac joint fusion and spinal cord stimulator handout with the details.

Washington State says it is not covered, and ACOEM says it is not recommended.  The newest set of ODG says generally not recommended, but there are exceptions. In the criteria for each case, there are a lot of people who fit the criteria now proposed, and it should be approved. 

There are 3 sets of guidelines in 9 months, and they are not the same.  The guidelines have changed each time.  None of what is being proposed for discography, lumbar fusion, SI joint fusion, spinal cord stimulator, physical therapy for acute radiculopathy is entirely consistent with current best evidence as demonstrated by Washington State and ACOEM.

Mr. Prevot said that the 3 different guidelines were a result of feedback from trying to move the guidelines in a direction but stay unbiased based on revisiting the literature.  There’s a significant number of citations that accompany each of the guidelines.  The editors’ view of best practice is leaving options.   The intent of the editors was to review the literature and do intense critical appraisal of the literature. The literature is independently gathered by librarians in an extensive process.  They consider the consensus side of evidence-based medicine which is the input from the Medical Advisory Committee.    The input from the last 9 months is the process by which they got to this current guideline.    It is not intended to be 3 guidelines but the most up to date version of the guideline.

Dr. Talmage replied that when Washington State reviews a topic they usually publish a paper that is over 100 pages to explain their position.  ACOEM has thousands of references in the whole system, but for each individual topic there may be hundreds of references.  Two different groups are looking at the same evidence base with different conclusions.

There were extensive comments made on discography and spinal cord stimulation.  Dr. Snyder asked if there were any further evaluation of cervical fusion, cervical laminectomy, lumbar laminectomy and lumbar fusions, and sacroiliac fusions.  

In terms of the cervical and lumbar fusion sections, there was a lot of discussion of adjacent level disease.  Unless there is some new pathology associated with a new injury, adjacent level disease should never be covered under workers’ comp. 

Causation is different than the operation itself. 

There are 25% of the adjacent levels that deteriorate, but other levels that are not adjacent also deteriorate.  This implies that it is an inherent degenerative condition for the patient, and not necessarily work-related.  If trauma caused any of these, studies show that less than 10% of the disc herniations are caused by strenuous activities or trauma.  It’s a DNA issue with the disc, and to extrapolate additional levels that are mostly degenerative and call them work-related and tie it to a fusion done years before does not make any sense.     

Referring to operative criteria, if a patient has had single level fusion and documented adjacent level disease, is extending that fusion medically reasonable?   If there is pain in the distribution of a nerve root and it is the same nerve root that’s being compressed by the degenerative changes at the adjacent level, yes.

Within these criteria, is there anything within the fusion criteria, not the causation, that is not appropriate?  It is the same as any fusion, take it on an individual basis whether it is adjacent level or not.

Fusion for lower lumbar low back pain should include evidence of instability listhesis or standing lateral flexion extension X-rays and note that the degenerative disc disease and discogenic back pain is not a reason for a fusion.  

ODG said no on degenerative disease and the committee agrees with that based on the Tennessee guides.   It was noted that Dr. Talmage pointed out on ODG there were comments to the effect that back pain and spondylolisthesis could be treated with fusion.  There should be evidence of some instability to justify that procedure, not just a trace spondylolisthesis which is not that uncommon.

Dr. Talmage added that ACOEM on fusion for spondylolisthesis must prove instability, which is either flexion extension or comparing supine to standing films and prove instability is present or grade 2 or higher which is the same as Washington State. 

The 3-millimeter, 2-millimeter grade 1 spondylolisthesis, no instability does not get better with surgery, especially in workers’ comp. That is not recognized.   The other is a causation comment.  The newest ODG lumbar fusion for adjacent segment disease says if you have adjacent segment disease after a decompression at a prior level, that’s an indication for fusion if you meet the other criteria.  A discectomy or ASMI stenosis and decompression do not cause adjacent segment disease.  And yet, if you’ve had a decompression and the segment adjacent is now symptomatic, that’s a reason to do a fusion.  There’s no proven literature to support that.

Dr. Brophy asked if Mr. Prevot would say the editorial staff has articles that have 5-year follow-up on a workers’ comp subset that says SI joint fusion is a significant improvement?

Mr. Prevot did not have that information readily available but said he would take it back to the editorial staff.

Dr. Brophy asked if they differentiate in the ODG between the workers comp outcomes versus other from an evidence standpoint and recommendation standpoint?

Mr. Prevot answered that the editors tend to review and write with workers’ comp policy in mind.  It’s a very general statement but what is appropriate evidence-based treatment can be irrespective of whether it is a workers’ comp injury or another type of injury.  The editors write without workers’ comp policy in mind but don’t necessarily view the evidence differently. Some of the other guidelines have hundreds to thousands of articles.  They are looking at it from the same perspective.

Mr. Prevot offered to send the methodology behind how evidence is graded.  Every article that is cited has a grade.

Dr. Talmage commented that the older you are the more likely the SI joint is spontaneously fused by ageing.  There is no requirement in this 3^rd set of SI guidelines that there should be advanced imaging like CT to look at the SI joint and see if it’s already fused or not.  The new guidelines say that a local anesthetic injection into the SI joint that relieves the patient’s pain is an indication for fusion.

Dr. Fortin, famous for the Fortin Signs, suspected the SI joint might be the source of pain.  Fortin published 2 articles saying that if you inject X-ray dye with the local anesthetic and wait 20 or 30 minutes, you’ll see that dye commonly extravasates out of the joint onto the L5 or S1 nerve roots or onto the lumbosacral plexus.   If you put local anesthetic in the joint and say it relieved the pain, it may be because it left the joint and anesthetized neural structures.  If you look at the reviews of SI joint fusion, all the studies that will be listed are manufacturer funded by the manufacturers that make implants to do the fusion percutaneously.  Late 2024, there was the first randomized controlled trial published that did not have manufacturer funding and the comparator was sham surgery.   It found no benefit.  Manufacturer funding has biased results and in order to obtain unbiased results, you must look at non-manufacturer funded studies.

This is the third set of SI guidelines in 9 months.   It is an update of the prior guidelines released in July of 2024.

Mr. Prevot addressed the point on the diagnostic imaging, and the ODG lists that a CT scan or an MRI scan is required to rule out neural compression or other degenerative conditions that could cause pain.  It does not necessarily say a congenital fusion, but they require the imaging that would identify that and additional CT and MRI to look for destructive lesions.  The diagnostic injection of the SI joint is not by itself criterion for fusion.  It requires greater than 50% improvement, but it is coupled with several other items required to qualify for an SI fusion.  That is the intent of the way it is written.   He will take this back.  The other point is about manufacturer funded study.   The ODG by MCG is very sensitive to manufacturer sponsored literature.  It’s not considered in a peer review process as part of the critical appraisal of that literature.  This is not a perfect statement, but he will clear up that part of the fusion.  

Dr. Talmage responded to the statement in the third guideline that the imaging criteria of X-ray and MRI would be sufficient.   MRI is a poor study to see if there is spontaneous fusion; CT is much better.   According to the guidelines, X-ray and MRI would be sufficient.

Mr. Prevot said that CT is mentioned as an option.

Dr. Talmage motioned for himself and Dr. Brophy that the Medical Advisory Committee request Dr. Snyder to obtain from ACOEM access for all MAC members to the guidelines for the spine procedures section to permit the Medical Advisory Committee to consider replacing the ODG with ACOEM for surgical spine care.

Between now and the next committee meeting, Dr. Snyder could appoint a subcommittee to study both in more detail and come to a conclusion.

Dr. Cole seconded the motion.

The committee voted to proceed with the motion, no dissent.

 

AMA Guidelines®:

The AMA had 1 course on the guides and issued other information regarding the 6th Edition 2024.  It is not yet at a point where a definitive recommendation can be made to the committee.  The meeting packet included information on the Guides® themselves.  There are 3 or 4 articles to do with the 6^th Edition AMA Guides 2024 that identify the different methodologies and evaluations of those.  The committee will review those probably in the fall or next year.

One of the articles had to do with prominent hand surgeons who make some evaluations concerning statements in the guidelines for carpal tunnel syndrome.   If ODG has seen the article, the committee would like them to come back and address that in the fall.

There is also a review article in the British Journal of Medicine (BMJ) regarding interventional procedures for non-cancer spinal pain.  They have evidence on the strong recommendations against any of those injections. 

All the articles address proposals for both treatment and permanent impairment evaluations.

Dr. Snyder asked for questions.

 

Medical Fee Schedule:

The new rate were tables posted in March but required 2 revisions.

The last update was 5/8/2025 and the changes were for comparability of Telehealth visits with office visits.  The calculations were corrected for that.  Be aware of the revision dates on the rate tables.

There will be a public hearing for the Medical Fee Schedule update at 11:00am on 6/6/2025 at 2020 French Landing in the Tennessee Room. This is open to the public and available by telephone. Afterwards, there will be a 2-week written comment period in which the Bureau will take comments on the medical fee schedule updates.

There were several changes made.  

1.  clarification of Z codes which are subject to contract negotiations and not to be used within the global period. 
2. Provider reimbursements.   The suggestion is to reduce the physician reimbursement from 6 separate groups to 3 separate groups.   All physician specialties are increased to 200% of Medicare, chiropractic and therapies are increased to 180%.  Ortho neuro for the surgical component will stay the same, but evaluation and management will go up from 160% to 200%.
3. One modifier has been eliminated, but a modifier for the Certified Physicians Program has been added. 
4. Several technical corrections to outlier language, APC inpatient only list.  There were changes to non-emergency ambulance transfer, and the forms for the Medical Payment Committee.  
5. The anesthesia charges were looked at and they remain at the high end in the southeastern states.

The changes are posted on the Secretary of State’s website.  They are available for everybody to look at.

Ms. Shtab had a question about the proposal concerning pharmaceutical reimbursement, an additional reference to a Medicare negotiated rate.  Is there any more information about how the proposal came to be included?

Medicare negotiated rates affect the average wholesale price of pharmaceuticals.   It was included so that whatever happens with Medicare, since the fee schedule rates are Medicare based, that will be allowed within the pharmaceutical evaluation.

Dr. Kyser asked about global periods.  Dr. Snyder answered that it is a surgical period between 6 weeks and 3 months when providers can’t charge for office visits.

 

Legislative Update:

Ms. Terry reported on the administration bill that removed the sunset of the Next Step Program.  This program gives college tuition money of up to $5000.00 per year for 4 years for injured workers who are unable to return to their jobs following a work injury.

There is a 5-year extension of the sunset of the attorney fee award to attorneys for injured workers until 6/30/2030, 50-6-226(d)(2)(b).  This provision allows a judge to award attorneys ‘fees to an injured worker’s attorney if the denial by the employer was unreasonable.

The minimum age requirement for workers’ comp judges, the chief judge, and the workers’ comp appeals board judges is being raised from 30 to 35, and the minimum level of experience is raised from 5 to 7 years.

The maximum number of terms a judge can serve is increased from 3 to 4 terms.  Each term is for 6 years.  Governor Lee signed the bill on 3/28/2025, and it will take effect 7/1/2025.

The Advisory Council on Workers Comp was extended to 6/30/2031.

Last year, a bill was passed which gives firefighters a presumption regarding PTSD, and this presumption has been extended to law enforcement officers or emergency medical responders with PTSD because of responding to certain incidents that occur in the line of duty.

Another bill expanded the presumption for firefighters for cancer benefits by adding prostate cancer, breast cancer, and pancreatic cancer to the list of cancers for which a presumption is created that certain conditions or impairments for full time firefighters arose out of employment unless the contrary is shown by competent medical evidence.

There are 6 rules that are in various processes of rule review.  The Claims Handling Standards (0800-02-14) are with the governor’s office.  Case Management (0800-02-07) is with the Attorney General’s office.

Court rules are currently with the Governor’s Office.

Administrator Haley, Dr. Snyder, and Ms. Terry talked about Bill HB 996 by Martin, SB 911 by Hale that was proposed in legislation this past year.    That bill went to summer study, so it is not passed yet.

Basically, the bill expands psychologists’ scope of practice to ease the administrative burden on psychiatrists treating workers’ comp patients so more of them would be willing to see patients with more serious symptoms and address causation and ratings.   There is an initial certificate and an advanced certificate to prescribe. 

A prescribing psychologist is a doctoral level licensed psychologist who has completed additional training and holds a current valid certificate to prescribe, either initial or advanced. May also be referred to as a medical psychologist, per DEA.  This law would have given them prescriptive authority, the legal authority to evaluate and manage patients, prescribe, administer, discontinue or distribute medications and treatments, including narcotics and ECT, other lab tests or devices rational to psychological practice, limited to conditions within the scope of psychology, psychiatric, emotional, cognitive, behavioral, etc.

The initial certificate to prescribe is supervised authority for a licensed doctoral level psychologist.  It allows prescription under supervision by a physician.   The advanced certificate to prescribe has independent authority which gives current license to provide health services as a psychologist in the state, completion of a post-doctoral master’s in clinical psychopharmacology regionally accredited.

The core areas include life sciences, neurosciences, psychopharmacology, assessment, pathophysiology, ethics, legal issues, etc.  They must pass a board approved prescribing exam, a fellowship that involves seeing evaluation of over 100 patients supervised by a physician, 450 contact hours in the didactic program and application to board after completion of all requirements.

Out of state applicants can apply for an advanced certificate provided their previous certification meets the state requirements and they obtain or hold an in-state license at the doctoral level.  The board will define rules for renewal, and they must complete 20 additional hours of continuing education related to prescriptive authority every 2 years.  Under this law, a prescribing psychologist would have been able to prescribe psychotropic medications for behavioral health, emotional, cognitive or psychiatric disorders, generate prescriptions according to applicable law.  They may not administer ECT, prescribe narcotics or opioids, or prescribe for patients not also under the care of a physician or primary care provider.

Prescription requirements must comply with state and federal laws, and clearly identify the prescribing psychologist.  Each prescription must be documented in the patient’s record.  The DEA and pharmacy coordination requires that the board must maintain DEA registration records.  Prescribing psychologists would be eligible for a DEA certificate, but the board must maintain the registration.  The DEA registration records notify the pharmacy Board of active prescribers, including name, ID and date, notify the Pharmacy Board promptly of termination suspensions or reinstatement.  The authority for other health professionals may carry out valid orders from prescribing psychologists if the order is within the psychologists’ legal scope of practice.  There could be disciplinary action by the board, and the board must create the rules for denying, modifying, suspending, or revoking prescriptive authority.  The board may require remediation of the psychologist’s practice if it poses a public health risk.

Dr. Snyder commented that this has gone to summer study so it will probably come up next year as another bill.  Mr. Haley added that it would probably be amended in some form and will come back in January.    There is an access to care issue in Tennessee, probably in other states, and not just in workers’ comp.  Dr. Kyser is one of the few psychiatrists who take workers’ comp patients in Tennessee.  This is almost at a crisis point and the committee does not have any direct influence on this bill but anything the committee could recommend addressing this issue would be much appreciated.

Dr. Kyser commented that the Tennessee Psychiatric Association will fight this. Psychologists are not medically trained and should not be prescribing medication.  The access argument is a much more diluted argument.  It’s been even more diluted by nurse practitioners.  Many of them are psychiatric nurse practitioners.  Community mental health centers across the state are staffed by many psychiatric nurse practitioners.  There are many in private practice that may not be willing to treat workers’ comp patients. 

Dr. Snyder added that the problem will be in billing and collection since they are not used to dealing with workers’ compensation.   The biggest problem is in accounting, not an issue of treatment.   In the mental health field, many of the providers do not want to deal with the accounting.  Possibly, the solution is to be more proactive with nurse practitioners and psychiatrists.

An issue of access to care are problems with getting providers paid no matter who they are.   Rural access is important, but psychologists work mostly practice in cities.  Psychiatry has been dealing with access to care in terms of collaborative health.  There is focus on collaborative care and working with primary care to expand access. 

(Dr. Tutor left the meeting).

 

Medicare Update:

The Congressional budget bill did not include a change in Medicare, so there is a 2.8% reduction in the Medicare rate which affects workers’ comp: from $33. 2028 to $32.3465.  That is part of the reason for recommending increases for the Medical Fee Schedule.

Dr. Kyser shared a document; he posted it in the chat.

 

UR Report:

Dr. Snyder shared the utilization review annual report on his screen.

There are 41 UROs registered in Tennessee.   Of these, 23 reported activities in the state of Tennessee, and 17 reported no activity.   One company has not reported.

Virtually all the UR companies that have activities are reporting to the Bureau.  These 23 companies used 413 physicians. The total number of determinations is 11,184, and of that number the approvals totaled 5,481.   The difference between these 2 numbers would make up the number of denials and modifications.

The denials/modifications are approximately 50% of the determinations.   Only about 1,400 of the denials are appealed to the Bureau which leaves approximately 3,500 denials/modifications that are not appealed.   Those individuals are either not receiving needed treatment or accepting the modified treatment.  

The appeals received by the Bureau are about 50/50 when it comes to uphold or overturn decisions.   

There are approximately 10,000 denied cases in Tennessee that would have potentially benefited the patient had they been appealed. 

There are UR organizations that reported to the Bureau that they did not have any utilization review activity in the state of Tennessee.

The organizations reported the number of physicians in each organization and their specialty and the number of different specialties and the number of companies that use those physicians.  They also reported the number of modifications that occurred.

There are 26 physicians that have done over 50 utilization reviews in Tennessee.  Dr. Alpert did the most.   Dr. Tontz did 695 utilization reviews.  Dr. Alpert is used by 10 different utilization review companies.     

This report shows success in investigating the UR activity in the state of Tennessee.

Dr. Snyder or Ms. Conner can be emailed to request the full report.

Penalties:

Most of the penalty letters sent since the last meeting concerned fee schedule violations and particularly Z codes, and not UR activity.

New Business

WCRI Reports:

Dr. Snyder has 3 WCRI reports that can be summarized.  The full WCRI reports cannot be sent outside the Bureau but those interested can go to WCRI.

The first WCRI report had to do with medical workforce changes.  Nationally, it looked at physician supply and availability in workers’ comp across the country which has been reduced.  Nurse practitioners and physician’s assistants have filled the need.  Workers’ compensation represents 40% of all new injury first appointments and more than 40% in rural areas.  The figure in 2013 was 13% and now it’s over 40%.

Full prescriptive authority has gone to more nurse practitioners and physician’s assistants in more states where they no longer have co-signature requirements.

There has been a slight increase in the temporary disability payments when nurse practitioners were involved, but no significant impact on total costs to the claim.  The pandemic related changes that had to do with cost, injury rates, medical workforce stresses and alternative work situations have gradually disappeared.  The injury rates that dropped significantly because of the reduction in construction and other activities that occurred around the COVID have essentially gone back to a normal curve.

The next study had to do with degenerative and co-morbid conditions in workers’ compensation.  This study included 32 states and 930,000 claims with over 70 days of lost time.  Co-morbidities were undertreated by most treating physicians.  The number of co-morbid conditions rises with age and there is no significant change in the gender differences. Sixty percent of spine injuries had one or more of the listed conditions.   Those with chronic pain had more co-morbidities listed; and those with greater than 4 co-morbidities had more lost time and higher indemnity costs than those who had less.  The average length of time for neurologic, neck and low back injuries was 70 weeks lost time compared to less than 7 days lost time for most injuries.  These were likelier for older individuals and retirement was an option rather than returning to work.

The third one was the effect of marijuana on workers’ injuries.    There was an analysis from 2012 to 2022, and overall, claims frequency declined in all states.  It was less in states with recreational marijuana which means that those state with recreational marijuana didn’t have an increase in their claims.  There was less of a decrease in states that didn’t have recreational marijuana.

Opioid prescriptions dropped in most states that had recreational marijuana.  However, it wasn’t clear that this wasn’t due to differences in prescribing patterns that happened between 2012 and 2022.

Claims duration and overall costs dropped in states with recreational marijuana.

 

Announcements:

• Next Meeting: 9/23/2025
• Second Meeting: 11/4/2025

Adjournment: 

2:45 PM CDT.