Rep. Jay Hoffman

Filed: 5/14/2018

 

 


 

 


 
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1
AMENDMENT TO SENATE BILL 904

2    AMENDMENT NO. ______. Amend Senate Bill 904 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. The Workers' Compensation Act is amended by
5changing Sections 8.2 and 8.2a as follows:
 
6    (820 ILCS 305/8.2)
7    Sec. 8.2. Fee schedule.
8    (a) Except as provided for in subsection (c), for
9procedures, treatments, or services covered under this Act and
10rendered or to be rendered on and after February 1, 2006, the
11maximum allowable payment shall be 90% of the 80th percentile
12of charges and fees as determined by the Commission utilizing
13information provided by employers' and insurers' national
14databases, with a minimum of 12,000,000 Illinois line item
15charges and fees comprised of health care provider and hospital
16charges and fees as of August 1, 2004 but not earlier than

 

 

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1August 1, 2002. These charges and fees are provider billed
2amounts and shall not include discounted charges. The 80th
3percentile is the point on an ordered data set from low to high
4such that 80% of the cases are below or equal to that point and
5at most 20% are above or equal to that point. The Commission
6shall adjust these historical charges and fees as of August 1,
72004 by the Consumer Price Index-U for the period August 1,
82004 through September 30, 2005. The Commission shall establish
9fee schedules for procedures, treatments, or services for
10hospital inpatient, hospital outpatient, emergency room and
11trauma, ambulatory surgical treatment centers, and
12professional services. These charges and fees shall be
13designated by geozip or any smaller geographic unit. The data
14shall in no way identify or tend to identify any patient,
15employer, or health care provider. As used in this Section,
16"geozip" means a three-digit zip code based on data
17similarities, geographical similarities, and frequencies. A
18geozip does not cross state boundaries. As used in this
19Section, "three-digit zip code" means a geographic area in
20which all zip codes have the same first 3 digits. If a geozip
21does not have the necessary number of charges and fees to
22calculate a valid percentile for a specific procedure,
23treatment, or service, the Commission may combine data from the
24geozip with up to 4 other geozips that are demographically and
25economically similar and exhibit similarities in data and
26frequencies until the Commission reaches 9 charges or fees for

 

 

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1that specific procedure, treatment, or service. In cases where
2the compiled data contains less than 9 charges or fees for a
3procedure, treatment, or service, reimbursement shall occur at
476% of charges and fees as determined by the Commission in a
5manner consistent with the provisions of this paragraph.
6Providers of out-of-state procedures, treatments, services,
7products, or supplies shall be reimbursed at the lesser of that
8state's fee schedule amount or the fee schedule amount for the
9region in which the employee resides. If no fee schedule exists
10in that state, the provider shall be reimbursed at the lesser
11of the actual charge or the fee schedule amount for the region
12in which the employee resides. Not later than September 30 in
132006 and each year thereafter, the Commission shall
14automatically increase or decrease the maximum allowable
15payment for a procedure, treatment, or service established and
16in effect on January 1 of that year by the percentage change in
17the Consumer Price Index-U for the 12 month period ending
18August 31 of that year. The increase or decrease shall become
19effective on January 1 of the following year. As used in this
20Section, "Consumer Price Index-U" means the index published by
21the Bureau of Labor Statistics of the U.S. Department of Labor,
22that measures the average change in prices of all goods and
23services purchased by all urban consumers, U.S. city average,
24all items, 1982-84=100.
25    (a-1) Notwithstanding the provisions of subsection (a) and
26unless otherwise indicated, the following provisions shall

 

 

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1apply to the medical fee schedule starting on September 1,
22011:
3        (1) The Commission shall establish and maintain fee
4    schedules for procedures, treatments, products, services,
5    or supplies for hospital inpatient, hospital outpatient,
6    emergency room, ambulatory surgical treatment centers,
7    accredited ambulatory surgical treatment facilities,
8    prescriptions filled and dispensed outside of a licensed
9    pharmacy, dental services, and professional services. This
10    fee schedule shall be based on the fee schedule amounts
11    already established by the Commission pursuant to
12    subsection (a) of this Section. However, starting on
13    January 1, 2012, these fee schedule amounts shall be
14    grouped into geographic regions in the following manner:
15            (A) Four regions for non-hospital fee schedule
16        amounts shall be utilized:
17                (i) Cook County;
18                (ii) DuPage, Kane, Lake, and Will Counties;
19                (iii) Bond, Calhoun, Clinton, Jersey,
20            Macoupin, Madison, Monroe, Montgomery, Randolph,
21            St. Clair, and Washington Counties; and
22                (iv) All other counties of the State.
23            (B) Fourteen regions for hospital fee schedule
24        amounts shall be utilized:
25                (i) Cook, DuPage, Will, Kane, McHenry, DeKalb,
26            Kendall, and Grundy Counties;

 

 

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1                (ii) Kankakee County;
2                (iii) Madison, St. Clair, Macoupin, Clinton,
3            Monroe, Jersey, Bond, and Calhoun Counties;
4                (iv) Winnebago and Boone Counties;
5                (v) Peoria, Tazewell, Woodford, Marshall, and
6            Stark Counties;
7                (vi) Champaign, Piatt, and Ford Counties;
8                (vii) Rock Island, Henry, and Mercer Counties;
9                (viii) Sangamon and Menard Counties;
10                (ix) McLean County;
11                (x) Lake County;
12                (xi) Macon County;
13                (xii) Vermilion County;
14                (xiii) Alexander County; and
15                (xiv) All other counties of the State.
16        (2) If a geozip, as defined in subsection (a) of this
17    Section, overlaps into one or more of the regions set forth
18    in this Section, then the Commission shall average or
19    repeat the charges and fees in a geozip in order to
20    designate charges and fees for each region.
21        (3) In cases where the compiled data contains less than
22    9 charges or fees for a procedure, treatment, product,
23    supply, or service or where the fee schedule amount cannot
24    be determined by the non-discounted charge data,
25    non-Medicare relative values and conversion factors
26    derived from established fee schedule amounts, coding

 

 

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1    crosswalks, or other data as determined by the Commission,
2    reimbursement shall occur at 76% of charges and fees until
3    September 1, 2011 and 53.2% of charges and fees thereafter
4    as determined by the Commission in a manner consistent with
5    the provisions of this paragraph.
6        (4) To establish additional fee schedule amounts, the
7    Commission shall utilize provider non-discounted charge
8    data, non-Medicare relative values and conversion factors
9    derived from established fee schedule amounts, and coding
10    crosswalks. The Commission may establish additional fee
11    schedule amounts based on either the charge or cost of the
12    procedure, treatment, product, supply, or service.
13        (5) Implants shall be reimbursed at 25% above the net
14    manufacturer's invoice price less rebates, plus actual
15    reasonable and customary shipping charges whether or not
16    the implant charge is submitted by a provider in
17    conjunction with a bill for all other services associated
18    with the implant, submitted by a provider on a separate
19    claim form, submitted by a distributor, or submitted by the
20    manufacturer of the implant. "Implants" include the
21    following codes or any substantially similar updated code
22    as determined by the Commission: 0274
23    (prosthetics/orthotics); 0275 (pacemaker); 0276 (lens
24    implant); 0278 (implants); 0540 and 0545 (ambulance); 0624
25    (investigational devices); and 0636 (drugs requiring
26    detailed coding). Non-implantable devices or supplies

 

 

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1    within these codes shall be reimbursed at 65% of actual
2    charge, which is the provider's normal rates under its
3    standard chargemaster. A standard chargemaster is the
4    provider's list of charges for procedures, treatments,
5    products, supplies, or services used to bill payers in a
6    consistent manner.
7        (6) The Commission shall automatically update all
8    codes and associated rules with the version of the codes
9    and rules valid on January 1 of that year.
10    (a-2) For procedures, treatments, services, or supplies
11covered under this Act and rendered or to be rendered on or
12after September 1, 2011, the maximum allowable payment shall be
1370% of the fee schedule amounts, which shall be adjusted yearly
14by the Consumer Price Index-U, as described in subsection (a)
15of this Section.
16    (a-3) Prescriptions filled and dispensed outside of a
17licensed pharmacy shall be subject to a fee schedule that shall
18not exceed the Average Wholesale Price (AWP) plus a dispensing
19fee of $4.18. AWP or its equivalent as registered by the
20National Drug Code shall be set forth for that drug on that
21date as published in Medispan.
22    (b) Notwithstanding the provisions of subsection (a), if
23the Commission finds that there is a significant limitation on
24access to quality health care in either a specific field of
25health care services or a specific geographic limitation on
26access to health care, it may change the Consumer Price Index-U

 

 

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1increase or decrease for that specific field or specific
2geographic limitation on access to health care to address that
3limitation.
4    (c) The Commission shall establish by rule a process to
5review those medical cases or outliers that involve
6extra-ordinary treatment to determine whether to make an
7additional adjustment to the maximum payment within a fee
8schedule for a procedure, treatment, or service.
9    (d) When a patient notifies a provider that the treatment,
10procedure, or service being sought is for a work-related
11illness or injury and furnishes the provider the name and
12address of the responsible employer, the provider shall bill
13the employer or its designee directly. The employer or its
14designee shall make payment for treatment directly to the
15provider in accordance with the provisions of this Section.
16Providers and providers shall submit bills and records in
17accordance with the provisions of this Section.
18        (1) All payments to providers for treatment provided
19    pursuant to this Act shall be made within 30 days of
20    receipt of the bills as long as the bill claim contains
21    substantially all the required data elements necessary to
22    adjudicate the bill bills.
23        (2) If the bill claim does not contain substantially
24    all the required data elements necessary to adjudicate the
25    bill, or the claim is denied for any other reason, in whole
26    or in part, the employer or insurer shall provide written

 

 

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1    notification to the provider in the form of an explanation
2    of benefits , explaining the basis for the denial and
3    describing any additional necessary data elements, to the
4    provider within 30 days of receipt of the bill. The
5    Commission, with assistance from the Medical Fee Advisory
6    Board, shall adopt rules detailing the requirements for the
7    explanation of benefits required under this subsection.
8        (3) In the case (i) of nonpayment to a provider within
9    30 days of receipt of the bill which contained
10    substantially all of the required data elements necessary
11    to adjudicate the bill, (ii) of or nonpayment to a provider
12    of a portion of such a bill, or (iii) where the provider
13    has not been issued an explanation of benefits for a bill
14    up to the lesser of the actual charge or the payment level
15    set by the Commission in the fee schedule established in
16    this Section, the bill, or portion of the bill up to the
17    lesser of the actual charge or the payment level set by the
18    Commission in the fee scheduled established in this
19    Section, shall incur interest at a rate of 2% 1% per month
20    payable by the employer to the provider. Any required
21    interest payments shall be made by the employer or its
22    insurer to the provider not later than within 30 days after
23    payment of the bill.
24        (4) If the employer or its insurer fails to pay
25    interest required pursuant to this subsection (d), the
26    provider may bring an action in circuit court to enforce

 

 

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1    the provisions of this subsection (d) against the employer
2    or its insurer responsible for insuring the employer's
3    liability pursuant to item (3) of subsection (a) of Section
4    4. Interest under this subsection (d) is only payable to
5    the provider. An employee is not responsible for the
6    payment of interest under this Section. The right to
7    interest under this subsection (d) shall not delay,
8    diminish, restrict, or alter in any way the benefits to
9    which the employee or his or her dependents are entitled
10    under this Act.
11    (e) Except as provided in subsections (e-5), (e-10), and
12(e-15), a provider shall not hold an employee liable for costs
13related to a non-disputed procedure, treatment, or service
14rendered in connection with a compensable injury. The
15provisions of subsections (e-5), (e-10), (e-15), and (e-20)
16shall not apply if an employee provides information to the
17provider regarding participation in a group health plan. If the
18employee participates in a group health plan, the provider may
19submit a claim for services to the group health plan. If the
20claim for service is covered by the group health plan, the
21employee's responsibility shall be limited to applicable
22deductibles, co-payments, or co-insurance. Except as provided
23under subsections (e-5), (e-10), (e-15), and (e-20), a provider
24shall not bill or otherwise attempt to recover from the
25employee the difference between the provider's charge and the
26amount paid by the employer or the insurer on a compensable

 

 

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1injury, or for medical services or treatment determined by the
2Commission to be excessive or unnecessary.
3    (e-5) If an employer notifies a provider that the employer
4does not consider the illness or injury to be compensable under
5this Act, the provider may seek payment of the provider's
6actual charges from the employee for any procedure, treatment,
7or service rendered. Once an employee informs the provider that
8there is an application filed with the Commission to resolve a
9dispute over payment of such charges, the provider shall cease
10any and all efforts to collect payment for the services that
11are the subject of the dispute. Any statute of limitations or
12statute of repose applicable to the provider's efforts to
13collect payment from the employee shall be tolled from the date
14that the employee files the application with the Commission
15until the date that the provider is permitted to resume
16collection efforts under the provisions of this Section.
17    (e-10) If an employer notifies a provider that the employer
18will pay only a portion of a bill for any procedure, treatment,
19or service rendered in connection with a compensable illness or
20disease, the provider may seek payment from the employee for
21the remainder of the amount of the bill up to the lesser of the
22actual charge, negotiated rate, if applicable, or the payment
23level set by the Commission in the fee schedule established in
24this Section. Once an employee informs the provider that there
25is an application filed with the Commission to resolve a
26dispute over payment of such charges, the provider shall cease

 

 

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1any and all efforts to collect payment for the services that
2are the subject of the dispute. Any statute of limitations or
3statute of repose applicable to the provider's efforts to
4collect payment from the employee shall be tolled from the date
5that the employee files the application with the Commission
6until the date that the provider is permitted to resume
7collection efforts under the provisions of this Section.
8    (e-15) When there is a dispute over the compensability of
9or amount of payment for a procedure, treatment, or service,
10and a case is pending or proceeding before an Arbitrator or the
11Commission, the provider may mail the employee reminders that
12the employee will be responsible for payment of any procedure,
13treatment or service rendered by the provider. The reminders
14must state that they are not bills, to the extent practicable
15include itemized information, and state that the employee need
16not pay until such time as the provider is permitted to resume
17collection efforts under this Section. The reminders shall not
18be provided to any credit rating agency. The reminders may
19request that the employee furnish the provider with information
20about the proceeding under this Act, such as the file number,
21names of parties, and status of the case. If an employee fails
22to respond to such request for information or fails to furnish
23the information requested within 90 days of the date of the
24reminder, the provider is entitled to resume any and all
25efforts to collect payment from the employee for the services
26rendered to the employee and the employee shall be responsible

 

 

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1for payment of any outstanding bills for a procedure,
2treatment, or service rendered by a provider.
3    (e-20) Upon a final award or judgment by an Arbitrator or
4the Commission, or a settlement agreed to by the employer and
5the employee, a provider may resume any and all efforts to
6collect payment from the employee for the services rendered to
7the employee and the employee shall be responsible for payment
8of any outstanding bills for a procedure, treatment, or service
9rendered by a provider as well as the interest awarded under
10subsection (d) of this Section. In the case of a procedure,
11treatment, or service deemed compensable, the provider shall
12not require a payment rate, excluding the interest provisions
13under subsection (d), greater than the lesser of the actual
14charge or the payment level set by the Commission in the fee
15schedule established in this Section. Payment for services
16deemed not covered or not compensable under this Act is the
17responsibility of the employee unless a provider and employee
18have agreed otherwise in writing. Services not covered or not
19compensable under this Act are not subject to the fee schedule
20in this Section.
21    (f) Nothing in this Act shall prohibit an employer or
22insurer from contracting with a health care provider or group
23of health care providers for reimbursement levels for benefits
24under this Act different from those provided in this Section.
25    (g) On or before January 1, 2010 the Commission shall
26provide to the Governor and General Assembly a report regarding

 

 

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1the implementation of the medical fee schedule and the index
2used for annual adjustment to that schedule as described in
3this Section.
4(Source: P.A. 97-18, eff. 6-28-11.)
 
5    (820 ILCS 305/8.2a)
6    Sec. 8.2a. Electronic claims.
7    (a) The Director of Insurance shall adopt rules to do all
8of the following:
9        (1) Ensure that all health care providers and
10    facilities submit medical bills for payment on
11    standardized forms.
12        (2) Require acceptance by employers and insurers of
13    electronic claims for payment of medical services.
14        (3) Ensure confidentiality of medical information
15    submitted on electronic claims for payment of medical
16    services.
17        (4) Ensure that health care providers have an
18    opportunity to comply with requests for records by
19    employers and insurers for the authorization of the payment
20    of workers' compensation claims.
21        (5) Ensure that health care providers are responsible
22    for supplying only those medical records pertaining to the
23    provider's own claims that are minimally necessary under
24    the federal Health Insurance Portability and
25    Accountability Act of 1996.

 

 

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1        (6) Provide that any electronically submitted bill
2    determined to be complete but not paid or objected to
3    within 30 days shall be subject to interest pursuant to
4    item (3) of subsection (d) of Section 8.2.
5        (7) Provide that the Department of Insurance shall
6    impose an administrative fine if it determines that an
7    employer or insurer has failed to comply with the
8    electronic claims acceptance and response process. The
9    amount of the administrative fine shall be no greater than
10    $1,000 per each violation, but shall not exceed $10,000 for
11    identical violations during a calendar year.
12    (b) To the extent feasible, standards adopted pursuant to
13subdivision (a) shall be consistent with existing standards
14under the federal Health Insurance Portability and
15Accountability Act of 1996 and standards adopted under the
16Illinois Health Information Exchange and Technology Act.
17    (c) The rules requiring employers and insurers to accept
18electronic claims for payment of medical services shall be
19proposed on or before January 1, 2012, and shall require all
20employers and insurers to accept electronic claims for payment
21of medical services on or before June 30, 2012. The Director of
22Insurance shall adopt rules by September 1, 2018 to implement
23the changes to this Section made by this amendatory Act of this
24100th General Assembly. The Commission, with assistance from
25the Department and the Medical Fee Advisory Board, shall
26publish on it its Internet website a companion guide to assist

 

 

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1with compliance with electronic claims rules. The Medical Fee
2Advisory Board shall periodically review the companion guide.
3    (d) The Director of Insurance shall by rule establish
4criteria for granting exceptions to employers, insurance
5carriers, and health care providers who are unable to submit or
6accept medical bills electronically.
7(Source: P.A. 97-18, eff. 6-28-11.)
 
8    Section 99. Effective date. This Act takes effect upon
9becoming law.".