Penalties For Violations Of Fee Schedule Rules

(1) Except when a waiver has been 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 these Rules, Medical RULES FOR MEDICAL PAYMENTS CHAPTER 0800-02-17 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 these Rules, Medical Fee Schedule Rules or the Inpatient Hospital Fee Schedule Rules, shall be in violation of these Rules and may, at the Administrator’s discretion, be subject to civil penalties of not less than fifty dollars ($50) nor more than five thousand dollars ($5,000) per violation, which may be assessed severally against the provider accepting such fee and the employer paying the excessive fee, except as authorized pursuant to T.C.A. § 50-6-204, whenever a pattern or practice of such activity is found. Any provider reimbursed or employer 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. 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. Any other violation of these Rules, Medical Fee Schedule Rules, or the Inpatient Hospital Fee Schedule Rules shall subject the 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, Administrator’s Designee, or an agency member appointed by the Administrator. (2) A provider or employer found to be in violation of these Rules, may request a contested case hearing by requesting the hearing in writing within fifteen (15) business days of issuance of a Notice of Violation and, if applicable, notice of the assessment of civil penalties. If a request for hearing is not received by the Bureau within the fifteen (15) business days of issuance of the Notice of Violation, the determination of such violation shall be deemed a final order of the Bureau and not subject to further review. All rights, duties, obligations, and procedures applicable under the Bureau’s Rules for Penalty Assessments and Hearing Contested Cases (Chapter 0800-02-13) are applicable under these Rules, including, but not limited to, the right to judicial review of any final Bureau decision. (3) A request for hearing shall be made to the Bureau in writing by an employer or provider notified of violation of these Rules. (4) Any request for a hearing shall be filed with the Bureau within fifteen (15) business 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) business days of the date of issuance of the 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. (5) The Administrator, Administrator’s Designee, or an agency member appointed by the Administrator 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 Rules for Penalty Assessment and Hearing Contested Cases, Chapter 0800-02-13, shall apply and be followed in any such contested case hearing. (6) Upon receipt of a timely filed request for a hearing, the Administrator shall issue a Notice of Hearing to all interested parties.