Fee schedule caps what Fresenius owes for the care it denied

The worker had the surgery anyway, using an unauthorized provider, and kept treating. He later claimed the unauthorized back treatment totaled $562,783.85. The employer put the figure at $147,979.91. 

At trial, the court found the back injury compensable and ordered the employer to pay the unauthorized bills – but only at the fee-schedule rate. The worker appealed that limit, arguing the employer should cover the full cost of care it refused. 

The Appeals Board disagreed. It held that the trial court had to apply the fee schedule to all reasonable and necessary bills from a compensable injury, whether the treatment was authorized or not. State law caps an employer’s liability at the fee-schedule amount, the board said, and no statute or regulation treats denied treatment differently. If the rule is to change, the board added, that is a job for the legislature. 

For HR and workers’ comp teams, the decision cuts two ways. Denying recommended treatment on the strength of second opinions still carries risk – if the claim is later found compensable, the employer pays. But that exposure is capped at the fee schedule, even for care the employer turned down. The ruling gives claims handlers a clearer ceiling when weighing whether to authorize disputed care. 

The board also noted protections for the worker. Under Tennessee rules, providers generally cannot chase a compensation claimant for unpaid balances, and a worker who pays out of pocket for compensable care must be fully reimbursed – potentially above the fee-schedule amount. The board called the worker’s fear of being left “holding the bag” speculative and not ripe.