►
Description
House Insurance Subcommittee - March 16, 2021 - House Hearing Room 2
A
A
C
A
B
A
A
A
Of
course,
our
legislators
will
present
at
the
podium,
but
if
you
are
asked
to
to
speak
on
a
particular
piece
of
legislation,
we
would
like
to
keep
our
initial
comments
reserved
to
roughly
three
minutes
beyond
three
minutes.
You'll
be
able
to
engage.
Our
members
will
be
able
to
ask
questions
of
of
you
if
there
are
any
pertinent
questions
to
to
follow
up.
Testimony
that
you
may
have
today's
calendar
is
an
emotional
calendar.
I'll
be
very
frank.
A
Lots
of
folks
have
spoken
to
us
on
on
the
calendar
before
us
today
and
it's
it's
critically
important
to
the
health
and
welfare
of
our
state
and
our
citizens
of
tennessee.
So,
as
with
that
being
said,
I
look
forward
to
taking
up
the
calendar.
As
I
look
to
my
colleagues
to
my
right.
My
left
are
there
any
personal
orders
that
anyone
has
at
the
moment.
A
B
Mr
chairman,
I'm
working
with
stakeholders
on
both
sides
of
this
legislation
and
if
it's
okay
with
this
committee,
I'd
like
to
roll
that
a
week
to
get
this
in
the
best
posture
possible
for
both
the
patient
providers
etc.
So
then
I'll
be
prepared
to
present
that,
as
we
continue
to
make
this
a
proper,
proper
and
good
bill.
A
Thank
you
very
much,
and
the
representative
has
approached
me
earlier
and
has
asked
ask
for
what
you've
just
seen.
I
asked
for
the
continuing
work
on
this
legislation
and
for
a
role,
and
it's
certainly
granted
so
without
objection
house
bill
1195
will
be
rolled
one
week.
Thank
you,
mr
chairman
committee.
I
appreciate
it.
Thank
you.
A
B
B
The
340b
drug
discount
program
is
a
u.s
federal
government
program
created
in
1992
that
requires
drug
manufacturers
to
provide
outpatient
drugs
to
eligible
health
care
organizations
and
covered
entities
at
significantly
reduced
prices.
The
law
requires
the
savings
be
used
on
patient
care.
Pbms
are
trying
to
reduce
or
eliminate
the
savings
for
more
than
25
years.
The
340b
drug
discount
pro
pricing
program
has
provided
financial
help
to
eligible
safety,
net
hospitals
and
clinics
serving
tennessee's
most
vulnerable
patients.
B
A
D
D
So
basically,
what
representative
helton
covered
is
that
the
340b
program
was
established
in
the
late
90s
and
it
was
created
to
help
give
a
discount
to
safetynet
providers,
and
what
pbms
are
looking
to
do
is
to
usurp
that
savings
into
their
pockets.
So
if
we
don't
get
the
discount,
then
that
means
that
for-profit
entities
can
capture
some
of
those
savings
and
that's
not
what
congress
intended
and
absent
state
legislation
to
help
protect
us.
E
Mr
chairman,
I
do
want
to
take
an
opportunity
to
recognize
the
director,
ms
stevenson,
because
indeed
it
is
an
underestimate,
a
underestimated
statement
for
them
to
say
that
they've
been
on
the
front
lines
of
the
coveted
response
in
hamilton
county.
So
I
want
to
recognize
you
for
that.
If
you
wouldn't
mind,
I
know
that
when
we
talk
about
ryan
white
clinics,
many
people
here
know
that.
But
I
want
you
to
want
people
to
understand
back
home
and
if
you
wouldn't
offer
testimony
the
typical
patient
that
comes
to
you
are
dealing
with
they're
hiv
positive.
E
They
have
immunosuppression
and
any
other
host
of
disease
that
may
be
leading
into
a
very
chronic
debilitating
state,
and
these
people
are
most
likely
and
if
you
wouldn't
speak
to
this
uninsurable,
they're
not
they're
trying
to
work.
But
but
the
reason
this
is
important
is
what
we're
trying
to
prohib
prevent
and
stop
is
insurance
companies
from
profit
sharing,
essentially
off
of
this
particular
grant.
But
if
you
wouldn't
mind
speaking
to
the
typical
patients
that
you
all
treat.
Thank
you,
mr
chairman,
mrs
stevenson,.
D
So
our
goal
has
been
and
thankfully,
to
the
340b
program,
our
viral
load
suppression
in
five
years
time
has
gone
from
73
to
93,
meaning
that
93
of
our
patients
no
longer
transmit
the
virus
to
others.
So
we
offer
social
services
behavioral
health
substance
abuse
if
they
need
it,
and
always
the
primary
care
and
clinical
care
for
infectious
disease.
A
A
The
question
is
called
in
the
objection
to
the
question,
seeing
none
all
those
in
favor
of
house
bill,
1348
going
to
full
insurance
committee,
please
signify
by
saying
aye
aye
any
of
those
opposed.
Please
say
no,
the
eyes
have
it
the
bill
moves
forward.
Thank
you,
mr
chairman
and
committee.
Thank
you
chair,
lady
hilton.
A
C
C
This
bill
adds
chiropractic
services
performed
by
a
person
authorized
to
engage
in
the
practice
of
chiropractic
through
the
list
of
health
care
services
that
may
be
included
as
covered
10
care.
Medical
assistants.
This
bill
requires
that
the
medical
assistance
provided
by
tenncare
include
payment
for
chiropractic
services
for
recipients
who
are
18
years
of
age
or
older.
Currently,
chiropractic
services
are
covered
for
children
up
to
age
18,
but
then
are
no
longer
covered
for
18
years
of
age
or
older.
I
see
this
bill
as
helping
with
the
substance
abuse
problem
that
faces
so
many
tennesseans.
C
Instead
of
going
to
a
physician
and
getting
pain,
meds
or
requiring
someone
to
have
surgery.
This
gives
the
patient
another
option
that
hopefully,
can
address
their
paintings
without
opioids
or
surgery
committee.
I
stand
before
you
as
a
someone
who
does
use
chiropractic
care.
I've
used
it
my
entire
athletic
career,
and
I'm
telling
you
right
now.
I
would
not
be
standing
here
in
front
of
you
without
chiropractic
care.
C
A
G
C
To
answer
that
question,
I
don't
know
two
years
ago
I
asked
that
question
of
tenncare
and
I
couldn't
figure
out.
I
asked
them.
Is
there
any
physiological
difference
that
happens
after
age
18
in
the
human
body
that
chiropractic
care
wouldn't
work,
and
the
answer
was
no,
so
I've
been
perplexed
as
this.
If
we're
trying
to
provide
the
best
care
we
can
for
our
recipients
of
tenncare,
this
could
hopefully
maybe
give
another
option
instead
of
getting
on
opioids
or
going
through
expensive
or
very
costly
back
surgery.
B
I
don't
have
a
question.
I
just
have
a
comment
and
I
share
your
passion
for
chiropractics
my
I
have
a
niece
there's
a
chiropractor.
My
whole
family
is
big
proponents
of
chiropractory
and
thank
you
for
bringing
this
bill.
I
really
agree
with
you
and
think
that
it
will
make
a
big
difference
in
people's
lives
and
keep
them
off.
Like
you
said,
drugs.
A
A
F
F
There
are
really
two
components
with
this
bill
that
tenncare
has
a
concern
with
one
is
the
inability
for
us
to
be
able
to
prior
authorize
these
services
and
second
would
be
the
inability
for
us
to
perform
or
for
mcos
to
perform
alternative
services
such
as
physical
therapy,
occupational
therapy
other
steroidal
drugs.
We
do
think
that
this
would
have
a
fiscal
impact.
That's
likely
more
significant
than
what's
listed
in
the
official
fiscal
note,
and
also
the
inability
to
prior
authorize
or
offer
alternative
services
goes
against
the
medical
necessity
criteria
that
we
have
laid
out
in
statute.
F
E
E
F
E
F
It
would-
and
I
may
ask
dr
vaughn
for
jean
to
come
up
to
speak
to
that
more,
but
I
think,
as
is
with
chiropractic
services
too,
there
tends
to
be.
You
know
where
it's
not
just
one
visit.
There
are
multiple
visits
that
they
may
have
over
the
course
of
you
know
a
long
period,
whereas
with
maybe
some
of
these
other
services
they
could
go,
and
even
if
it
elevates
to
a
back
surgery
or
a
spinal
surgery
that
that
would
alleviate
the
problem
or
then
no
additional
care
would
be
needed.
A
A
C
Is
the
bill
adds
chiropractic
care?
Is
he
speaking
to
the
point
that
chiropractic
care
doesn't
work
over
the
age
of
21
and
that's
why
we
shouldn't
do
it?
Because
if
it's
a
financial
issue,
why
we
shouldn't
do
it?
This
body
determines
what's
financially
acceptable
that
we're
going
to
pay
for
so
I'm
curious
to
see
if
the
doctor
is
testifying
that
chiropractic
care
does
not
work.
Okay,.
A
H
I
appreciate
the
opportunity
to
be
here
today,
I'm
vaughn
for
jean
I'm
a
physician.
I
work
with
tenncare.
I
think
I
can
clarify
that
question.
I
appreciate
that
and
I'll
clarify
also
what
ashley
said.
So
I
think
the
question
was
raised
is
why
do
we
cover
chiropractic
care
up
to
the
age
of
21
and
not
over
21.
H
So
it's
not
to
say
that
adult
chiropractic
treatment
is
not
a
value
or
beneficial
in
some
circumstances
and
even
in
some
circumstances
may
be
medically
necessary.
The
reason
that
we
don't
cover
it
is
it's
not
part
of
our
state
plan
amendment.
It's
not
part
of
our
agreement
with
the
federal
government
where
we
can
pay
for
it,
so
so
any
any
movement
to
cover
it
for
adults
for
anyone
over
age
21.
We
would
have
to
go
back
to
the
federal
government
and
essentially
negotiate
that
state
plan
amendment
to
get
coverage
for
adults
over
21..
Thank.
C
We
have
the
ten
care
block
grant,
but
we
know
our
opponents
on
the
other
side
of
the
aisle
have
asked
the
biden
administration
to
revoke
our
10
care
block,
grant,
which
means
we'd
have
to
go
and
renegotiate
a
contract
coming
up.
So
we
could,
if
the
general
assembly
says
yes,
we
want
to
add
chiropractic
care
and,
yes,
we
want
to
fund
it.
When
you
go
to
renegotiate
or
ask
for
an
amendment,
you
would
just
have
to
ask
for
an
amendment
on
our
policy
correct.
That
is
correct.
Thank
you.
H
Yeah,
so
there
there's
essentially
two
things
with
the
bill
that
we
have
concerns
about.
One
is
the
fiscal
impact
associated
with
adding
additional
chiropractic
services,
and
the
second
part
is
the
language
that
says
that
we
cannot
require
alternative
services
be
used
before
providing
payment
for
chiropractic
services.
We
schedule
our
ability
to
prior
authorize
those
services,
so
that
would
mean
essentially
that
we
were
treating
chiropractic
services
different
than
any
other
type
of
treatment,
so
for
any
other
type
of
medication
or
surgery
or
physical
therapy.
H
Anything
there's
an
element
of
a
prior
authorization
process,
that's
in
place
based
on
our
definition
of
medical
necessity.
So
I
don't
think
it
would
be
a
question
of
dealing
with
with
the
federal
government.
We
still
have
to
negotiate
that
state
plan
amendment,
but
it
would
if,
if
that
requirement
for
alternative
services
not
being
used
was
removed,
there
would
still
be
the
fiscal
impact
associated
with
it.
I
I
H
So
I
think
one
of
the
issues
that
would
raise
earlier
would
chiropractic
treatment,
potentially
save
money
and
and
would
lessen
some
services.
And-
and
we
looked
at
that-
we
looked
at
when
we
looked
at
other
states
and
and
our
conclusion
from
that
is
that
adding
an
additional
service
would
lead
to
increased
cost.
I
H
I
A
Thank
you
and
I'll
read
from
the
the
fiscal,
the
other
fiscal
impact
that
we
have
just
to
clarify
and
maybe
add
to
this
the
conversation
of
the
fiscal
impact.
There
could
be
savings
if
chiropractic
care
is
used
in
lieu
of
other
procedures
due
to
a
number
of
unknown
factors.
The
timing
and
amount
of
any
savings
are
not
quantifiable
with
reasonable
certainty.
A
C
H
C
Everybody
that
qualifies
for
10
care
in
the
state
of
tennessee
is
on
tent
care.
That
is
correct.
That
is
correct,
so
we
have
a
fixed
pool
and
if
we
have
out
of
that
pool
right
now,
we
have
back
surgery,
we
have
opioids,
we
have
other
things
that
they
can
possibly
do.
If
we
add
one
more
in
there,
it's
just
another
tool
and
a
tool
belt
for
tenncare
to
provide
outstanding
insurance.
C
The
thing
that's
the
most
troubling
here
is:
I
keep
hearing
money,
we're
quantifying
healthcare
with
money
instead
of
doing
what's
right
for
our
for
our
people
on
tenncare
and
if
we
can
provide
average
back
surgery,
sixty
thousand
dollars
and
from
the
private
sector.
What
I
pay
for
a
visit
for
ten
care
are
for
chiropractic
care
is
roughly
a
hundred
dollars.
C
That
means
for
that
sixty
thousand
dollars.
You
could
treat
somebody
600
times
with
chiropractic
care
600
times
and
if
we,
if
we
did
that
and
still
stayed
away
from
back
surgery
or
stayed
away
from
opioids,
the
benefits
of
that
outweigh
the
cost
of
that
sixty
thousand
dollars.
So
we
don't
ruin
people's
lives
with
opioid
addiction,
which
we
have
a
rampant
problem
in
tennessee
with.
C
I
would
argue
that
I
would
argue
that
the
fiscal
note
is
wrong,
because
it's
the
same
people
who
are
taking
advantage
of
this
are
either
going
to
choose
back
surgery,
they're
going
to
choose
opioids
or
they're,
going
to
choose
chiropractic
care.
Personally,
I
would
hope
they
would
choose
chiropractic
care
or
maybe
physical
therapy,
before
they
would
under
the
surgeon's
knife
or
start
hitting
us
up
for
drugs.
C
A
E
But
would
you
be
willing
to
accept
a
friendly
amendment
that
we
could
work
on
over
the
next
day,
or
so
that
would
maybe
cap
the
number
of
visits
to
potentially
two
or
three
a
month
and
number
two
put
this
in
a
position
that
it
would
be
under
a
prior
authorization
type
format,
so
that
it
would
leave
discretion
to
the
department
hoping
that
it
fits
into
an
episode
of
care
that
comes
before
surgery
and
or
opioids?
Thank
you,
mr
chairman.
C
So
I
do
understand
your
amendment
and
I
understand
it's
a
friendly
amendment.
I
would
consider
it
a
friendly
amendment.
However,
chair
larry
lady
we've
gone
through
this
before
last
year
with
tenncare,
and
every
time
we
came
up
with
a
solution.
They
came
up
with
another
problem.
Okay
and
I
I
really
don't
want
to
get
into
this
dance
with
them
again.
C
I
believe
the
general
assembly
is
the
one
that
has
to
make
the
call
here.
Do
we
want
to
make
our
healthcare
better?
If
you
want
me
to
roll
this
for
a
week
and
work
on
that
amendment,
as
long
as
tenncare
will
tell
me
right
now
that
that's
a
friendly
amendment
and
they'll
consider
the
friendly
amendment
get
neutral
on
the
bill,
then
I
would
consider
adding
that
to
it.
E
Thank
you,
mr
chairman,
and
here's
what
I
would
say:
I'm
not
in
the
driver's
seat.
The
chairman
of
this
committee
is
that
here's.
What
I
would
tell
you
I'm
going
to
vote
for
your
amendment,
I'm
going
to
vote
for
your
bill
if
they
will
not
commit
to
that.
But
I
will
be
glad
to
work
with
you
and
add
that
amendment
and
vote
for
your
bill,
then,
because
I
do
think
that
this
is
something
we're
dealing
with
a
crisis.
E
That's
causing
premature
death
and
changing
our
longevity
of
life
because
of
opioids
and
the
cost
of
surgery-
and
I
know
the
fiscal
node
is
going
to
be
fluid
because
it
it's
you're
in
the
cont
you're
in
the
continuum
of
care.
So
I
would
commit
to
you,
as
I
would
prefer,
to
work
with
you
on
an
amendment,
but
I
don't
have
the
I'm
not
queen
for
the
day,
and
so
I
can't
make
tenncare
make
a
promise
like
that.
So
thank
you,
mr
chairman.
A
C
But
in
my
opinion,
once
we
get
that
language,
we
would
have
to
have
the
commitment
from
tenncare
that
now
they're
neutral
on
the
bill
and
therefore
we
can
move
this
forward,
and
then
we
have
to
start
looking
for
money
for
this.
If
we
get
to
a
point
that
the
amendment
is
made
and
tenncare
still
doesn't
sign
off
on
it,
then
I
would
bring
this
bill
back
next
week
in
his
current
form
and
run
the
bill.
If
that's
okay,
with
the
chairman.
I
Thank
you
chairman.
I
was
just
going
to
echo
some
of
the
comments
of
representative
smith
on.
I
think
that,
if
we
put
if
we're
able
to
to
work
on
guardrails
on
this,
I
think
it
may,
on
the
front
end,
hit
help
the
fiscal
note
and
I
think,
maybe,
on
the
back
end,
it
might
help
us
with
our
shared
savings
and
but
we
have
to
have
the
right
guard
rails,
and
I
think
that
that's
something
that
we
can
work
on
outside
this.
So
thank
you.
A
G
Well,
thank
you.
I
think
the
matter
has
been
is
moving
in
the
right
direction
and
I'm
pleased
with
that.
I
just
wanted
to
make
an
observation
that
chiropractic
care,
especially
in
certain
age
groups,
beyond
much
beyond
21,
is
a
recognized
specialty
and
a
field
that
has
real
benefits
to
it,
and
I'm
surprised
that
it
is
not.
We
cover
a
lot
of
other
care
things
under
10
care,
and
certainly
this
would
improve
lives,
and
I
think
it
needs
to
be
done
and
I'm
pleased
that
our
committee
and
the
sponsor
are
working
towards
a
good
solution.
A
Thank
you,
dr
kumar.
What
the
chair
is
hearing
is
that
there
is
a
request
to
roll
this
piece
of
legislation
as
we
work
toward
an
amendment.
The
request
will
be
that
we
continue
work
with
our
with
tenncare
to
show
them
the
work
that
we
have
in
hand
and
move
forward
with
a
product
in
committee
next
week
and
we'll
continue
to
have
those
conversations
as
chair
lady
smith,
eloquently
said
she
could
not
be
queen
for
the
day.
A
A
E
Thank
you,
mr
chairman.
Yes,
just
for
the
purpose
of
getting
to
some
of
these
other
bills
and
to
to
partner
the
last
bill
with
the
first,
they
tend
to
go
better
together.
The
network
adequacy,
as
well
as
the
surprise
billing
they
tend
to
feed
off
of
each
other.
So
if
it's
okay
with
the
committee
and
the
chairman,
I'd
like
to
proceed
now
to
house
bill
145,
which
is
a
number
five
on
the
calendar,
okay.
A
A
Right
do
we
have
a
motion
in
a
second
on
house
bill
145,
you
have
a
motion.
We
have
a
second.
We
are
now
looking
at
an
amendment
language
to
house
bill
145
which,
in
my
view,
looks
to
be
the
amendment
that
will
make
this
bill.
That's
correct,
chairman
before
you,
ladies
and
gentlemen,
we
have
amendment
tracking
code.
3897.
A
Ladies
and
gentlemen,
you
have
before
you
amendment
3897,
to
house
bill
145..
I
will
entertain
a
motion
in
a
second.
If
it's
there,
we
have
a
motion
and
a
second
on
amendment
drafting
code,
3897,
all
those
in
favor
of
placing
this
amendment
on
the
bill.
Please
signify
by
saying
aye
aye
any
opposed,
say
no,
the
eyes
have
it
charity
smith.
We
are
on
house
bill
145
for
your
explanation.
That
is,
as
it
has
been
amended.
Thank
you,
mr
chairman.
E
And
committee
in
tennessee
we
have
pharmacy
benefit
managers.
We
heard
a
little
bit
of
discussion
about
this
earlier
in
the
form
of
the
340b
legislation.
This
particular
bill
enables
and
instructs
our
department
of
commerce
and
insurance
to
create
a
more
robust
licensure
process
that
adds
to
the
current
licensure.
Today,
the
pharmacy
benefit
managers
are
licensed
on
a
biennial
basis.
Every
two
years,
the
once
they're
licensed
at
a
hundred
dollars.
Their
renewal
fee
is
fifty
dollars
every
other
year
and
there
are
very
few
criteria.
E
This
particular
bill
is
written
145
and,
as
amended,
will
increase
that
licensure
to
a
thousand
dollars
with
the
renewal
every
two
years
to
500.
It
will
also
instruct
the
pharmacy
benefit
managers
to
act
in
the
best
interest
of
the
patient
that
are
insured
rather
than
the
insurance
entity
or
the
pharmacy
or
the
pharmacist,
or
the
insurance
plan
operating
as
a
third
party
administrator
and
further.
It
will
set
up
a
complaint
process
very
similar
to
what
this
body
has
heard
before
a
wonderful
process
that
I
know,
one
of
the
investigators
vicky
trice
is
over.
E
There
is
a
complaint
process
so
this
by
no
means
changes
or
puts
into
code
specifications
on
benefits
or
contracts.
Instead,
it
prioritizes
the
patient's
interest,
as
that
which
is
protected
by
the
pharmacy
benefit
managers
in
the
state
of
tennessee.
It
also
allows
the
department
an
opportunity
to
use
the
licensure
to
ensure
quality
as
well
as
to
make
sure
that,
if
a
pharmacy
benefit
manager
has
an
unfortunate
record
of
a
lot
of
complaints
that
they
can
use
that
to
revisit
their
licensure,
and
with
that,
mr
chairman
I'll,
be
happy
to
take
questions.
A
See
none
are
you
ready
to
vote
and
all
those
in
favor
of
sending
house
bill
145
as
amended
to
full
insurance
committee?
Please
signify
by
saying
aye
aye
any
of
those
opposed.
Please
say
no,
the
eyes.
Have
it
house
bill
145,
as
amended,
we'll
go
to
full
insurance
committee.
Thank
you,
mr
chairman.
Ladies
and
gentlemen,
we
are
now
on
item
number
six
on
our
calendar
today
and
that
is
house
bill
635.
As
I
turn
the
page
that
is
also
being
presented
by
representative
smith,
representative
smith,
you
are
recognized
on
house
bill
635.
E
A
We
have
a
motion
in
in
second
on
house
bill
635,
we
have
a
before
us.
We
have
amendment
tracking
code,
four,
five,
one,
four,
that's
correct!
Yes,
sir,
ladies
and
gentlemen,
we
have
amendment
tracking
code,
four,
five,
one,
four.
We
have
a
motion
and
a
second
on
the
amendment,
any
questions
on
the
amendments.
Let's
go
ahead
and
put
it
on.
Ladies
and
gentlemen,
all
those
in
favor
of
placing
amendment
tracking
code
4514
on
house
bill
635,
please
signify
by
saying
aye
aye
any
of
those
opposed.
A
E
Thank
you,
mr
chairman
and
committee
in
the
in
the
state
of
tennessee.
We
have
a
definition
of
medical
necessity
or
medically
necessary,
that's
in
code
and
also
in
the
state
of
tennessee
in
our
practice
of
medicine.
Definition
as
well
is
in
our
practice
of
the
healing
arts
of
medicine
definition,
there's
some
language
that
specifically
says
that
there
is
nothing
that
will
restrict
the
physician
from
exercising
independent
medical
judgment
in
diagnosing
and
treating
patients
in
tennessee
code
63-6-204.
E
Also
in
6811
205.
It
says
that
employee
employing
entities
shall
not
restrict
or
interfere
with
medically
appropriate
diagnosed
diagnostic
or
treatment
decisions,
and-
and
hence
we
find
ourselves
in
a
con
in
a
conflict,
because
the
practice
of
in
tennessee
in
in
our
code,
the
term
medical
necessity
and
or
medically
necessary,
has
been
put
into
code
in
perpendicular
position
to
that
definition
of
the
practice
of
medicine,
meaning
that
if
dr
david
hawk
is
my
physician
and
you
encounter
me
as
a
patient.
Believe
me.
E
E
This
does
not
prevent
utilization
review
and
even
the
amendment
that
we
added
colleagues,
this
pulls
out
workers
compensation,
because
the
workers
compensation
administration
uses
nationally
recognizes
recognized
occupational
diagnostic
guidelines,
and
so,
if
physicians,
that
are
impaneled
to
oversee
patients
that
are
being
treated
for
workforce
injuries
as
long
as
they
are
explicitly
using
those
guidelines,
they
are
out
that
is
already
determined
as
medically
necessary
in
this
particular
bill.
It
would
apply
to
the
the
the
the
application
of
commercial
insurance,
insurance
and
I'll
be
happy
to
work
with
my
colleagues
at
tenncare.
E
This
did
receive
a
favorable
recommendation
for
the
council
on
pensions
and
insurance,
but
we
can
make
some
minor
adjustments
but
again
back
to
the
premise
of
this
bill.
It's
to
prioritize
patients
and
doctors,
making
sure
that
medically
necessary
is
determined
by
the
examining
physician
who
has
possession
of
the
medical
record
and
not
anyone
that
would
be
in
a
third
party
position
and
with
that,
mr
chairman,
I
will
gladly
take
questions.
A
Thank
you
very
much
and
I'll
begin.
The
questioning
and
forgive
me
as
I
was
looking
at
the
amendment
this
morning
and
thank
you
for
for
the
work
on
this,
and
I
should
have
asked
you
this
previously,
I'm
wondering
about
if
the
department
of
health
has
an
actionable
item,
if
there
is
a
concern
of
concern
with
the
physician
that
something
was
improper
and
properly
ordered,
and
their
action
has
to
be
taken
by
someone
at
the
department
of
health.
A
E
A
E
A
I
E
Thank
you,
mr
chairman,
and
and
as
I
understand
the
question
that's
being
asked
is
if
someone
were
under
review
or
disciplinary
observation,
you
know
there
are
processes
already
in
in
place
for
boards
of
medical
examination
and
other
practice
opportunities
for
people
to
be
put
on
supervision
for
having
their
license
suspended.
Things
like
that.
So
I
would
not
be
concerned
about
the
inability
to
intervene
if
someone
was
practicing
in
a
malpractice
type
situation,
but
in
this
case,
just
like
I'll
give
an
example
in
the
council
on
pensions
and
insurance.
E
Sometimes
it
just
prolongs
access
to
to
a
medical
treatment,
and
in
I
dare
say
that
all
I
can
there
is
someone
who
sat
in
my
office
in
recent
days
who
missed
10
days
of
work
because
they
are
having
to
to
go
an
alternative
path
for
care,
for
an
injury
just
to
meet
the
terms
of
the
the
insurance
company
as
opposed
to
what
their
doctor
wants,
and
so
we're
we're.
Seeing
people
that
are
out
of
work.
We're
seeing
people
that
are
are
paying
additional
health
care
costs,
rather
than
just
getting
what
their
physician
wants.
E
So
in
this
particular
case,
what
this
law
would
do
is
just
all
throughout
code,
reverse
the
burden
of
proof
for
medical
necessity
to
be
disproven
by
the
insuring
entity
or
the
bureau.
The
bureaucracy,
as
opposed
to
the
physician
or
provider,
who
has
spent
any
number
of
years,
studying
license
being
licensed
under
their
medical
board
of
medical
examiners,
as
well
as
carrying
the
the
medical
malpractice
policy.
I
Thank
you,
representative
smith,
brought
up
a
a
point
about
the
state
denying
outside
medical,
necessary
and,
and
that
brought
me
to
a
bill
that
I
happened
to
run
several
years
ago.
That
did
not
pass
and
my
question
you
may
know
this.
You
may
not
know
this
the
denial
for
medical
necessary,
the
the
the
entities
that
denied
this
were
the
physicians
on
their
staff
that
denied
that
were
they
licensed
in
the
state
of
tennessee.
E
That's
a
great
question:
I
don't
know
that.
I
know
that
in
in
certain
practices
and
in
insurance
they
will
hire
consultants
to
serve
as
their
utilization
review
and
their
peer
panel.
Sometimes
those
people
are
indeed
licensed
in
the
state
of
tennessee,
sometimes
they're
not.
But
that
is
something
that
you
know.
Insurance
companies
employ
various
professionals,
but
they
don't
necessarily
have
to
by
code,
be
licensed
in
the
state
of
tennessee.
G
E
E
G
Thank
you.
So
if
a
physician
recommends
and
recommends
an
mri,
the
guidelines
that
the
insurance
company
has
say,
the
patient
is
not
ready
for
that.
They
should
have
so
many
weeks
of
physical
therapy
and
so
on.
Then,
how
will
the
determination
be
made
in
that
scenario?
Would
the
guidelines
trump,
the
physician
judgment
or
with
the
physician
determination
that
this
is
medically
necessary
trump?
The
guidelines.
E
If,
if
someone
has
a
a
back
injury,
there
are
different
levels
of
pain,
there's
different
types
of
recording
in
the
medical,
the
patient
medical
record
as
you're
aware
that
will
change
the
level
of
acuity
and
move
that
patient
to
a
more
critical
stage
than
someone
that
has
just
a
mild
strain
as
opposed
to
radiculopathy
loss
of
function,
the
inability
to
return
to
work,
those
type
things
and
what
I
would
just
challenge
the
thought
process
is.
You
know
this
is
not
rhetorical.
E
Are
we
going
to
honor
our
tennessee
code,
annotated
and
allow
physicians
to
practice
medicine
and
are?
Are
we
going
to
have
medical
necessity
listed
in
code
that
will
parallel
that
and
support
that
and
and
allow
the
burden
of
proof
that
they're
witnessing
they're
seeing
the
patient
a
peer
review
person
never
touches
the
patient,
they
never
have
the
patient
squeeze
their
hand
and
experience
grip,
loss
and
change
of
muscle,
tone,
etc
and
and
again
not
to
burden
the
the
insurance.
E
G
Germany,
thank
you
I
mean
as
clinicians.
We
have
all
struggled
with
the
situation
where
we
know
this
patient
needs
this
and
quote
the
insurance
company
didn't
approve
it.
We've
all
struggled
with
that
and
we
have
been
advocates
for
those
patients
calling
and
having
peer-to-peer
peer
conferences
with
the
review
person
at
the
insurance
company
and
generally
they've,
been
very
helpful,
but
still
we've
all
struggled
with
that.
I
still
don't
I'm
not
getting
able
to
determine
if
there
is
a
conflict
between
guidelines
and
the
physician
judgment
who
will
make
the
decision?
E
I
would
just
simply
thank
you,
mr
chairman.
I
would
just
simply
respond
that
you
know.
Physicians
and
providers
are
very
reasonable
if
guidelines
are
clear
and
they
support
a
patient
presentation,
then
I
think
that
the
practitioner
would
would
comply.
I
don't
think
that
that
most
physicians
in
the
state
of
tennessee
and
or
providers
would
be
unreasonable
to
press
the
the
issue
again.
This
is
just
going
back
to
what
we're
seeing
more
and
more
cost.
G
B
I
want
to
thank
you,
as
we've
talked
to
my
office
recently
for
carrying
this
bill.
This
is
very
personal
to
me
because
I
know
the
heartache
and
the
time
that
patients
sometimes
of
someone
else
getting
between
the
doctor
and
the
patient.
My
daughter
falls
in
that
category
she's
very
smart
person.
She
advocates
for
herself
a
lot
of
times
as
we've
talked
there's.
Sometimes
people
are
not
able
to
do
that
and
they're
not
able
to
be
able
to
argue
with
insurance
companies
and
advocate
for
themselves.
B
My
daughter
does
not
live
in
the
state
of
tennessee,
but
I
support
this
bill.
I
think
it's
very
important
for
the
doctor
and
the
patient
to
have
that
relationship
but-
and
I
do
understand
about
cost
savings-
I
would
be
an
advocate
for
that,
but
I
think
there
comes
a
time
when
the
doctor
has
to
be
his
opinion
has
to
be
respected
and
people
that
are
sick.
Just
we.
We
should
recognize
and
honor
that
as
well
as
we
honor
and
recognize
cost
savings.
B
There's
a
time
when
we
have
to
say
the
doctor
knows
best,
and
these
patients
should
not
have
to
sit
on
the
phone
for
hours
and
advocate
for
themselves
through
insurance
companies
to
try
to
get
a
mri
or
whatever
it
may
be.
So
very
personal,
a
situation
to
me.
I
support
your
bill.
Thank
you
for
bringing
it.
A
We
do
have
some
folks
on
the
list
who
would
like
to
test
to
testify
or
just
like
to
speak
about
the
legislation
we
have
tennessee
department
of
commerce
and
insurance,
both
alex
lewis
and
patrick
merkel.
If
one
of
you,
gentlemen,
would
like
to
speak.
In
addition,
we
have
individuals
from
tenncare
who
have
requested
to
speak
on
this
legislation,
I'll,
let
you
all
decide
who
would
like
to
go.
First,.
A
All
right
we
are,
we
will
go
into
recess
for
the
moment.
With
the
purpose
of
hearing
testimony,
we
will
begin
with
folks
from
tennessee
department
of
commerce
and
insurance.
Mr
lewis,
if
you
could
please
introduce
yourself,
tell
us
who
you
are
and
who
you're
with
and
and
begin
your
conversation
thank.
J
You
chairman,
I'm
alex
lewis
with
tennessee
department
of
commerce
and
insurance,
our
position
in
the
position
of
several
other
departments
who
may
want
to
speak
with
more
specificity,
health,
finance,
administration
and
tenncare
about
the
impact
to
their
departments
from
our
department.
We
see
this
as
an
undermining
of
the
way
that
insurance
and
health
care
works
right
now.
J
That
could
likely
lead
to
an
increased
cost
to
consumers,
we're
concerned
that
it
would
undermine
the
ability
of
insurance
companies
on
behalf
of
consumers
and
plan
sponsors
to
be
able
to
use
cost-saving
measures
in
order
to
ensure
that
the
plan
itself
is
in
good
shape.
So
from
the
department
standpoint,
that's
where
we
stand.
C
J
We
know
that
insurance
companies
use
utilization
utilization
review,
pre-certification
pre-authorization
in
order
to
ensure
that
best
practices
are
followed,
and
while
we
do
trust
our
providers,
we
do
know
that
there
are.
There
is
lots
of
academic
research
going
on
all
the
time
about
the
efficacy
and
the
efficiency
of
courses
of
treatment
and
the
benefit
of
the
utilization
review.
Pre-Certification
pre-authorization.
C
J
J
I
would
like
for
my
physician
to
have
the
access
to
the
greatest
amount
of
information
possible
and
pre-certifications
pre-authorizations.
Add
that
extra
layer
of
information
that
would
be
beneficial
to
me
as
a
consumer.
I
would
think-
and
and
I
know
that
as
the
cheerleading
said-
these
are
very
personal
situations
and
and
the
department-
that's
not
lost
on
the
department,
but
we
think
that
this
is
a
valuable
tool.
C
C
I
want
my
doctor
prescribing,
what's
best
for
me,
standing
in
front
of
him,
because
you're
different
than
I
am
everybody
here
is
different
from
each
other,
and
a
doctor
should
have
that
flexibility.
Now
I
understand
there
are
still
checks
and
balances
in
the
system
that
make
sure
that
there's
no
abuse
that
doctors
still
have
to
answer
to.
C
We
keep
circling
back
the
money
which
drives
me
crazy
in
healthcare.
It
always
keeps
circling
back
the
money.
I
know
I'm
not
on
the
education
committee
here,
but
I
keep
hearing
money
up
here
all
the
time
we
should
be
doing
what's
best
for
the
patient
period.
Okay,
now
I
understand
there's
insurance
companies.
I
understand
there's
other
people
involved
here.
I
understand
that
the
medical
profession
I
get
it
right
there
are.
Does
this
bill
eliminate?
J
I
Thank
you
chairman.
I
appreciate
you
coming
to
testify
and
this
bill
has
me
thinking
and
has
actually
has
me
going
back
to
when
I
was
an
intern
and
it's
a
case
that
I
remember
I'm
not
going
to
give
anything
away
from
a
hipaa
standpoint,
but
it's
imprinted
in
my
mind,
and
it
was
a
patient
that
came
in
and
my
attending
had
to
have
a
conversation
with
somebody,
and
he
said
this
patient
needed
x
and
said
it
was
medically
necessary
and
he
was
denied
and
said
you
have
to
go.
I
The
patient
took
it
upon
themselves
that
they
were
going
to
take
that
route
and
this,
even
though
the
person
they're
talking
to
on
the
phone
never
saw
the
patient
at
all
ends
up.
While
the
patient
was
waiting
for
to
have
another
procedure
done
that
the
physician
said
he
didn't
need
and
was
going
to
fail.
Anyway,
there
was
a
bad
outcome
for
that
patient.
I
I
G
Thank
you.
Thank
you,
mr
chairman,
and
thank
you,
mr
lewis,
for
your
explanation
of
things.
While
I'm
at
it.
Thank
you
chairman
smith,
for
bringing
this
up
it
makes
us
think,
makes
us
think
back
to
the
situations
we
have
come
across,
where
we
struggled
with
getting
approval
for
a
patient
who
much
needed
it,
and
also
at
just
a
few
months
ago.
I
was
tired
of
getting
injections
in
my
shoulders
and
it
was
not
getting
better
and
I
thought
I
needed
an
mri.
G
Our
insurance
turned
it
down
and
said
you
need
a
few
weeks
more
and
guess
what
my
insurance,
my
my
shoulder
was
better
a
few
weeks
later.
So
it's
life
is
a
balance
and
I
think
we're
trying
to
balance
his
patient
welfare
with
the
over
utilization
of
facilities
and
costs,
and
I
sincerely
after
a
lifetime
in
medicine.
G
A
A
F
Our
definition
of
medical
necessity
is
a
fundamental
principle
of
our
program
and
impacts
all
areas
of
spend,
if
required,
to
use
the
definition
of
medical
necessity
set
forth
in
this
bill.
We
would
be
unable
to
assure
members
receive
appropriate
care
and
would
see
significant
increases
in
our
cost
trend.
F
For
context,
we
have
not
been
able
to
find
a
medical
necessity,
definition
in
medicare,
commercial
insurance
or
42
other
medicaid
states
that
have
their
definition
of
medical
necessity
publicly
available.
That
is
identical
to
this
definition
or
one
that
places
the
burden
of
proof
on
the
insurance
entity.
F
It
is
also
about
ensuring
the
right
care
care
that
is
clinically
appropriate,
as
determined
by
the
medical
community,
using
the
most
current
medical
guidelines
and
criterias
examples
of
inappropriate
care
that
may
be
prescribed
in
the
absence
of
our
current
medical
necessity.
Definition
include
treatments
that
were
once
commonly
accepted
before
new
clinical
guidelines
changed.
F
These
include,
but
are
not
limited
to
the
overuse
of
antibiotics
for
sinusitis,
which
is
not
only
fiscally
irresponsible,
but
could
also
lead
to
antibiotic
resistance
and
be
harmful
to
the
patient.
An
additional
example
would
be
the
ordering
of
annual
electrocardiograms
or
any
other
cardiac
screening
for
low
risk
patients
without
symptoms.
F
There
is
little
evidence
that
detection
of
coronary
artery
stenosis
in
asymptomatic
patients
at
low
risk
for
coronary
heart
disease
improves
health
outcomes
boss.
Positive
tests
are
likely
to
lead
to
harm
through
unnecessary
invasive
procedures.
Over
treatment
and
misdiagnosis
potential
harms
of
this
routine
annual
screening
exceed
the
potential
benefit.
Both
of
these
examples
came
from
recommendations
of
the
american
academy
of
family
physicians.
F
This
legislation
also
has
significant
implications
for
the
tenncare
3
or
shared
savings
waiver,
as
you
may
have
heard
director
smith
say
for
us
to
succeed
and
earn
shared
savings
for
the
state.
All
that
we
need
to
do
is
continue
to
do
the
same
things
we've
been
doing
in
recent
years,
the
things
that
have
gotten
us
to
a
point
where
we
consistently
manage
costs
below
the
average
or
projected
growth
trend
for
medicaid
programs.
There
is
no
question
this
bill
changes
our
ability
to
maintain
that
success.
F
In
other
words,
we
would
effectively
be
spending
any
shared
savings
we
might
achieve
on
the
front
end
without
adding
any
new
services
benefits
or
members
served.
To
conclude,
this
bill
is
also
inconsistent
with
federal
regulations
requiring
that
states
establish
methods
and
procedures
to
prevent
the
unnecessary
utilization
of
services,
and
it
has
implications
regarding
the
federal
definition
of
medical
necessity.
A
E
I
know
that
there
are
two
different
mcos
and
that
may
change
there
may
be
more
mcos
that
are
are
contracted
under
tenncare
one,
two:
three,
whichever
iteration
we're
under
which
we
need
does
the
does
each
of
these
mcos
operate
on
the
same
identical
set
of
guidelines
and
is:
is
it
standardized
across
the
the
board
as
far
as
enforcement,
utilization,
review,
etc?
Thank
you,
mr
chairman.
Yes,.
F
We
currently
have
three
mcos.
This
definition
is
standardized,
it
is
set
in
rule
and
in
statute,
all
three
of
our
mcos
utilize,
this
same
rule,
which
has
really
provided
a
lot
of
consistency
for
providers
as
they
know
exactly.
What's
in
the
medical
necessity
definition
and
we
think
has
has
served,
served
well,
this
definition
being
in
statute
and
all
three
mcos
using
it.
C
K
Thank
you,
chairman
scott
mcnally,
division
of
benefits,
administration
with
department
of
finance
administration.
We
also
oppose
the
bill.
We
read
it
as
replacing
the
existing
statutory
definition
for
medical
necessity,
we're
in
a
little
bit
different
spot
as
tin
care,
because
we
don't
maintain
our
own
in-house
definition.
We
defer
this
largely
to
the
carriers,
except
for
instances
where
services
are
specifically
excluded
in
our
planned
documents,
and
it's
unclear
whether
that
would
apply
here
anyway.
K
The
definition
of
medical
necessity
that
we've
been
given
by
our
providers
does
mirror
what's
currently
in
statute.
That
would
require
medically
necessary
services
to
have
written
criteria
to
be
clinically
appropriate
to
not
be
primarily
for
the
convenience
of
the
patient
or
the
provider
and
to
not
have
a
therapeutic
or
diagnostic
equivalent
with
a
cheaper
cost.
K
So
we
don't
read
that
as
completely
doing
away
with
the
utilization
review.
We
do
read
it
as
changing
the
standard
and,
as
chairman
smith
had
mentioned,
I
think
we
had
saved
40
million
dollars
in
avoided
costs
in
2020
through
medical
necessity
reviews.
So
we
consulted
with
our
actuary
as
to
how
many
of
those
savings
we
would
likely
retain
if
the
bill
were
to
pass
and
their
opinion
is
that
we'd
lose
about
half.
K
K
G
Thank
you,
mr
chairman.
I'm
not
an
expert
and
don't
take
it
as
the
final
word,
but
my
impression
clinically
was
that
in
an
emergency
pre-authorization
and
so
on
does
not
really
matter.
You
go
on
because
emergencies
happen
after
the
insurance
company
offices
are
closed
and
as
well
as
weekends.
When
somebody
sees
somebody
in
the
emergency
room
and
they
need
to
be
admitted,
we
would
go
ahead
and
admit
them
and
then
utilization
review
people
would
look
at
it
on
monday
and
by
that
time
you've
taken
care
of
essential
things.
G
My
question
to
you
is
when
you
say
that
you
were
able
to
save
so
much
money
in
certain
situations,
using
the
proper
guidelines
that
you
have
and
not
allowing
either
procedure
or
a
test,
and
so
on.
You
were
able
to
save
that
money.
Is
there
a
mechanism
that,
when
we
deny
care
to
the
person
that
was
recommended
by
the
physician
and
the
insurance
company
denied
it
that
care
did
not
get
provided
six
weeks
later,
eight
weeks
later
somebody
follow-ups
and
looks
at
it.
What
was
the
outcome
in
the
sense
that
the
deniers?
G
K
Thank
you
chairman.
I
think,
since
we
don't
currently
provide
that
function,
I
don't
know
that
we
would
go
back
and
review
how
adverse
determinations
have
played
out
amongst
our
membership.
I
think
it's
a
it's
a
worthy
question
and
I
would
hope
that
you
know
to
go
back
to
current
questions.
We've
heard,
if
someone's
being
interjected
between
a
patient
and
provider,
I
think
it
makes
perfect
sense
to
make
sure
there's
scrutiny
on
those
decisions
that
are
being
made.
K
Of
course,
this
is
a
question
of
payment
right,
so
if
you
can
pay
the
cost,
if
you're
in
a
direct
primary
care
situation,
I
don't
believe
any
insurer
would
tell
you.
You
know
that
you
can't
have
a
service
if
you
are
asking,
in
our
case
the
state
to
fund
a
service
on
behalf
of
state
employees.
I
think
that's
why
we
think
that
you
know
the
existing
criteria
for
medical
necessity
are
appropriate.
G
A
Thank
you
for
the
questions
comments
committee.
I
ask
your
mr
mackinlay.
Thank
you
very
much
committee.
I
ask
your
forgiveness.
I
looked
at
my
list
and
mr
macanally
was
at
a
different
on
a
different
bill.
I
called
him
up
so
mr
macanally,
you
gotta,
you
got
a
freebie,
you
gotta
free
me
on
me,
and
that
is
my
mistake
and
I
apologize.
A
A
E
I
appreciate
your
indulgence.
I
just
wanted
to
close
with
this
comment.
The
definition
of
insurance
insurance
is
a
contract
represented
by
a
policy
in
which
an
individual
or
entity
receives
financial
protection
or
reimbursement
against
losses
from
an
insurance
company.
The
company
pulls
clients
risk
to
make
payments
more
affordable
for
the
insured
insurance
policies
are
used
to
hedge
against
risk
of
financial
loss,
both
large
and
small,
that
may
result
from
damage
to
the
insured
to
the
insured,
his
or
her
property,
or
from
liability
caused
to
a
third
party.
E
We
did
not
hear
the
practice
of
medicine.
We
did
not
hear
anything
in
that
about
the
patient's
best
interest
and
what
I
would
just
submit
that
the
the
deliberative
work
of
this
body
is
to
prioritize
patients
and
I'm
happy
to
work
with
stakeholders
as
we
move
this
bill
forward,
but
I
would
ask
the
committee
to
vote
in
the
affirmative
today
to
put
patients
first.
Thank
you,
mr
chairman.
A
Thank
you
parliamentary
procedure.
The
question
has
been
called.
The
sponsor
of
the
legislation
has
delivered
fine
comments.
We
will
now
vote
on
house
bill
635
as
amended
all
those
in
favor
of
house
bill.
635
has
amended
to
send
the
bill
to
full
insurance.
Please
signify
by
saying
aye
any
opposed.
Please
say:
no,
no,
the
eyes
have
it
your
bill
moves
forward.