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Commerce & Insurance panel reviews 2025 provider complaints, independent reviews
Summary
TennCare oversight staff reported rising provider complaints and summarized independent-review requests across managed-care plans for calendar year 2025, attributing spikes to durable medical equipment providers and TennCare’s shift of crossover-claim processing to MCOs.
TennCare oversight staff told the Commerce & Insurance panel that provider complaints and independent-review requests for calendar year 2025 showed notable concentration among certain providers and plan types.
Regina Nelson, compliance officer for the TennCare Oversight Division, opened the report with plan-by-plan counts for 2025, saying, “Beginning with WellPoint, as you can see from the report, the reversals top the upheld by a nominal margin,” and presenting totals and quarter-by-quarter figures for each managed-care organization.
The report listed WellPoint provider complaints for 2025 (total reported in the presentation: 264) and showed similar breakdowns for UnitedHealthCare (total reported: 129) and Volunteer State Health Plan (VSHP; quarterly totals reported and a year total of 483). Nelson also summarized independent-review requests: “WellPoint had a total of 25,” she said, and she reported 14 for United and 41 for VSHP. Nelson noted hospitals accounted for the largest share of independent-review requests and that a durable medical equipment provider filed a disproportionate number of reviews; she added that providers that pursued independent review “saw a return of $586096 for calendar year 2025.”
Panel members asked about an apparent year-over-year increase in provider complaints. Sherry Ernst of Covenant Health said the bottom of the report looked like an increase since 2019 and asked whether there was “a specific theme associated with those increases.” Lisa Jordan, assistant commissioner for the TennCare Oversight Division and the division’s designee to the panel, attributed much of the rise to changes in processing and a small number of providers: “There was a spike in complaints we received from a particular durable medical equipment provider. We also had some complaints that came in due to TennCare moving the processing of crossover claims to the MCOs,” she said.
Nelson and Jordan emphasized that counts vary year to year and that some provider-specific issues (DME denials and crossover-claim processing changes) appear to have driven parts of the increase. The panel did not take any vote on policy during the meeting; the presentation was informational and panel staff said they will continue monitoring complaint trends and runout claims.
The panel adjourned after scheduling a follow-up meeting; staff said they would continue to provide quarterly complaint and independent-review summaries.
