Sedgwick, one of the largest workers’ compensation claims-management firms in the United States, was penalized by Tennessee regulators more than any other company in the last five years.
But most of the fines have been relatively small, a consequence of a Tennessee workers’ compensation system that has been skewed against workers, the Memphis Commercial Appeal newspaper reported this week.
The investigative series also found that some out-of-state doctors, paid by employers, insurers and third-party administrators, have routinely denied surgeries during utilization reviews – without seeing patients or examining medical imaging. One New Jersey physician, licensed in Tennessee, has had his decisions appealed more than any others, and has been accused of insurance fraud and allowing a nurse to use his signature on utilization review reports.
Tennessee claimants’ attorneys have complained for years, since legislative reforms in 2013, that the state’s workers’ compensation fee structure makes it difficult to earn a reasonable fee representing injured workers. Many lawyers have dropped workers’ comp practice, forcing workers to navigate the system on their own, the newspaper and lawyers have reported.
The Commercial Appeal report said that Sedgwick may have been warned and fined by regulators more often than other TPAs because it’s larger than others and handles claims for some of Tennessee’s biggest employers. Penalties were issued over erroneous paperwork, mishandled surgery requests and lengthy denials of medical treatments.
But another company, Genex, performed about the same number of utilization reviews in recent years with few citations issued by the Tennessee Bureau of Workers’ Compensation, the news site reported.
Sedgwick responded with a statement from Max Koonce, its chief claims officer: “As part of the work we do in Tennessee, Sedgwick is mandated by the state to process the appropriate workers’ compensation claims through the utilization review program,” he said. “Our focus is to provide the best outcomes in supporting injured workers while following all state requirements and regulations in Tennessee.”
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