Illinois General Assembly - Full Text of SB0904
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Full Text of SB0904  100th General Assembly

SB0904enr 100TH GENERAL ASSEMBLY

  
  
  

 


 
SB0904 EnrolledLRB100 06276 SMS 16313 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
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
17August 1, 2002. These charges and fees are provider billed
18amounts and shall not include discounted charges. The 80th
19percentile is the point on an ordered data set from low to high
20such that 80% of the cases are below or equal to that point and
21at most 20% are above or equal to that point. The Commission
22shall adjust these historical charges and fees as of August 1,
232004 by the Consumer Price Index-U for the period August 1,

 

 

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12004 through September 30, 2005. The Commission shall establish
2fee schedules for procedures, treatments, or services for
3hospital inpatient, hospital outpatient, emergency room and
4trauma, ambulatory surgical treatment centers, and
5professional services. These charges and fees shall be
6designated by geozip or any smaller geographic unit. The data
7shall in no way identify or tend to identify any patient,
8employer, or health care provider. As used in this Section,
9"geozip" means a three-digit zip code based on data
10similarities, geographical similarities, and frequencies. A
11geozip does not cross state boundaries. As used in this
12Section, "three-digit zip code" means a geographic area in
13which all zip codes have the same first 3 digits. If a geozip
14does not have the necessary number of charges and fees to
15calculate a valid percentile for a specific procedure,
16treatment, or service, the Commission may combine data from the
17geozip with up to 4 other geozips that are demographically and
18economically similar and exhibit similarities in data and
19frequencies until the Commission reaches 9 charges or fees for
20that specific procedure, treatment, or service. In cases where
21the compiled data contains less than 9 charges or fees for a
22procedure, treatment, or service, reimbursement shall occur at
2376% of charges and fees as determined by the Commission in a
24manner consistent with the provisions of this paragraph.
25Providers of out-of-state procedures, treatments, services,
26products, or supplies shall be reimbursed at the lesser of that

 

 

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1state's fee schedule amount or the fee schedule amount for the
2region in which the employee resides. If no fee schedule exists
3in that state, the provider shall be reimbursed at the lesser
4of the actual charge or the fee schedule amount for the region
5in which the employee resides. Not later than September 30 in
62006 and each year thereafter, the Commission shall
7automatically increase or decrease the maximum allowable
8payment for a procedure, treatment, or service established and
9in effect on January 1 of that year by the percentage change in
10the Consumer Price Index-U for the 12 month period ending
11August 31 of that year. The increase or decrease shall become
12effective on January 1 of the following year. As used in this
13Section, "Consumer Price Index-U" means the index published by
14the Bureau of Labor Statistics of the U.S. Department of Labor,
15that measures the average change in prices of all goods and
16services purchased by all urban consumers, U.S. city average,
17all items, 1982-84=100.
18    (a-1) Notwithstanding the provisions of subsection (a) and
19unless otherwise indicated, the following provisions shall
20apply to the medical fee schedule starting on September 1,
212011:
22        (1) The Commission shall establish and maintain fee
23    schedules for procedures, treatments, products, services,
24    or supplies for hospital inpatient, hospital outpatient,
25    emergency room, ambulatory surgical treatment centers,
26    accredited ambulatory surgical treatment facilities,

 

 

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1    prescriptions filled and dispensed outside of a licensed
2    pharmacy, dental services, and professional services. This
3    fee schedule shall be based on the fee schedule amounts
4    already established by the Commission pursuant to
5    subsection (a) of this Section. However, starting on
6    January 1, 2012, these fee schedule amounts shall be
7    grouped into geographic regions in the following manner:
8            (A) Four regions for non-hospital fee schedule
9        amounts shall be utilized:
10                (i) Cook County;
11                (ii) DuPage, Kane, Lake, and Will Counties;
12                (iii) Bond, Calhoun, Clinton, Jersey,
13            Macoupin, Madison, Monroe, Montgomery, Randolph,
14            St. Clair, and Washington Counties; and
15                (iv) All other counties of the State.
16            (B) Fourteen regions for hospital fee schedule
17        amounts shall be utilized:
18                (i) Cook, DuPage, Will, Kane, McHenry, DeKalb,
19            Kendall, and Grundy Counties;
20                (ii) Kankakee County;
21                (iii) Madison, St. Clair, Macoupin, Clinton,
22            Monroe, Jersey, Bond, and Calhoun Counties;
23                (iv) Winnebago and Boone Counties;
24                (v) Peoria, Tazewell, Woodford, Marshall, and
25            Stark Counties;
26                (vi) Champaign, Piatt, and Ford Counties;

 

 

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1                (vii) Rock Island, Henry, and Mercer Counties;
2                (viii) Sangamon and Menard Counties;
3                (ix) McLean County;
4                (x) Lake County;
5                (xi) Macon County;
6                (xii) Vermilion County;
7                (xiii) Alexander County; and
8                (xiv) All other counties of the State.
9        (2) If a geozip, as defined in subsection (a) of this
10    Section, overlaps into one or more of the regions set forth
11    in this Section, then the Commission shall average or
12    repeat the charges and fees in a geozip in order to
13    designate charges and fees for each region.
14        (3) In cases where the compiled data contains less than
15    9 charges or fees for a procedure, treatment, product,
16    supply, or service or where the fee schedule amount cannot
17    be determined by the non-discounted charge data,
18    non-Medicare relative values and conversion factors
19    derived from established fee schedule amounts, coding
20    crosswalks, or other data as determined by the Commission,
21    reimbursement shall occur at 76% of charges and fees until
22    September 1, 2011 and 53.2% of charges and fees thereafter
23    as determined by the Commission in a manner consistent with
24    the provisions of this paragraph.
25        (4) To establish additional fee schedule amounts, the
26    Commission shall utilize provider non-discounted charge

 

 

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1    data, non-Medicare relative values and conversion factors
2    derived from established fee schedule amounts, and coding
3    crosswalks. The Commission may establish additional fee
4    schedule amounts based on either the charge or cost of the
5    procedure, treatment, product, supply, or service.
6        (5) Implants shall be reimbursed at 25% above the net
7    manufacturer's invoice price less rebates, plus actual
8    reasonable and customary shipping charges whether or not
9    the implant charge is submitted by a provider in
10    conjunction with a bill for all other services associated
11    with the implant, submitted by a provider on a separate
12    claim form, submitted by a distributor, or submitted by the
13    manufacturer of the implant. "Implants" include the
14    following codes or any substantially similar updated code
15    as determined by the Commission: 0274
16    (prosthetics/orthotics); 0275 (pacemaker); 0276 (lens
17    implant); 0278 (implants); 0540 and 0545 (ambulance); 0624
18    (investigational devices); and 0636 (drugs requiring
19    detailed coding). Non-implantable devices or supplies
20    within these codes shall be reimbursed at 65% of actual
21    charge, which is the provider's normal rates under its
22    standard chargemaster. A standard chargemaster is the
23    provider's list of charges for procedures, treatments,
24    products, supplies, or services used to bill payers in a
25    consistent manner.
26        (6) The Commission shall automatically update all

 

 

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1    codes and associated rules with the version of the codes
2    and rules valid on January 1 of that year.
3    (a-2) For procedures, treatments, services, or supplies
4covered under this Act and rendered or to be rendered on or
5after September 1, 2011, the maximum allowable payment shall be
670% of the fee schedule amounts, which shall be adjusted yearly
7by the Consumer Price Index-U, as described in subsection (a)
8of this Section.
9    (a-3) Prescriptions filled and dispensed outside of a
10licensed pharmacy shall be subject to a fee schedule that shall
11not exceed the Average Wholesale Price (AWP) plus a dispensing
12fee of $4.18. AWP or its equivalent as registered by the
13National Drug Code shall be set forth for that drug on that
14date as published in Medispan.
15    (b) Notwithstanding the provisions of subsection (a), if
16the Commission finds that there is a significant limitation on
17access to quality health care in either a specific field of
18health care services or a specific geographic limitation on
19access to health care, it may change the Consumer Price Index-U
20increase or decrease for that specific field or specific
21geographic limitation on access to health care to address that
22limitation.
23    (c) The Commission shall establish by rule a process to
24review those medical cases or outliers that involve
25extra-ordinary treatment to determine whether to make an
26additional adjustment to the maximum payment within a fee

 

 

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1schedule for a procedure, treatment, or service.
2    (d) When a patient notifies a provider that the treatment,
3procedure, or service being sought is for a work-related
4illness or injury and furnishes the provider the name and
5address of the responsible employer, the provider shall bill
6the employer or its designee directly. The employer or its
7designee shall make payment for treatment in accordance with
8the provisions of this Section directly to the provider, except
9that, if a provider has designated a third-party billing entity
10to bill on its behalf, payment shall be made directly to the
11billing entity. Providers and providers shall submit bills and
12records in accordance with the provisions of this Section.
13        (1) All payments to providers for treatment provided
14    pursuant to this Act shall be made within 30 days of
15    receipt of the bills as long as the bill claim contains
16    substantially all the required data elements necessary to
17    adjudicate the bill bills.
18        (2) If the bill claim does not contain substantially
19    all the required data elements necessary to adjudicate the
20    bill, or the claim is denied for any other reason, in whole
21    or in part, the employer or insurer shall provide written
22    notification to the provider in the form of an explanation
23    of benefits , explaining the basis for the denial and
24    describing any additional necessary data elements, to the
25    provider within 30 days of receipt of the bill. The
26    Commission, with assistance from the Medical Fee Advisory

 

 

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1    Board, shall adopt rules detailing the requirements for the
2    explanation of benefits required under this subsection.
3        (3) In the case (i) of nonpayment to a provider within
4    30 days of receipt of the bill which contained
5    substantially all of the required data elements necessary
6    to adjudicate the bill, (ii) of or nonpayment to a provider
7    of a portion of such a bill, or (iii) where the provider
8    has not been issued an explanation of benefits for a bill
9    up to the lesser of the actual charge or the payment level
10    set by the Commission in the fee schedule established in
11    this Section, the bill, or portion of the bill up to the
12    lesser of the actual charge or the payment level set by the
13    Commission in the fee schedule established in this Section,
14    shall incur interest at a rate of 1% per month payable by
15    the employer to the provider. Any required interest
16    payments shall be made by the employer or its insurer to
17    the provider not later than within 30 days after payment of
18    the bill.
19        (4) If the employer or its insurer fails to pay
20    interest required pursuant to this subsection (d), the
21    provider may bring an action in circuit court to enforce
22    the provisions of this subsection (d) against the employer
23    or its insurer responsible for insuring the employer's
24    liability pursuant to item (3) of subsection (a) of Section
25    4. Interest under this subsection (d) is only payable to
26    the provider. An employee is not responsible for the

 

 

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1    payment of interest under this Section. The right to
2    interest under this subsection (d) shall not delay,
3    diminish, restrict, or alter in any way the benefits to
4    which the employee or his or her dependents are entitled
5    under this Act.
6    The changes made to this subsection (d) by this amendatory
7Act of the 100th General Assembly apply to procedures,
8treatments, and services rendered on and after the effective
9date of this amendatory Act of the 100th General Assembly.
10    (e) Except as provided in subsections (e-5), (e-10), and
11(e-15), a provider shall not hold an employee liable for costs
12related to a non-disputed procedure, treatment, or service
13rendered in connection with a compensable injury. The
14provisions of subsections (e-5), (e-10), (e-15), and (e-20)
15shall not apply if an employee provides information to the
16provider regarding participation in a group health plan. If the
17employee participates in a group health plan, the provider may
18submit a claim for services to the group health plan. If the
19claim for service is covered by the group health plan, the
20employee's responsibility shall be limited to applicable
21deductibles, co-payments, or co-insurance. Except as provided
22under subsections (e-5), (e-10), (e-15), and (e-20), a provider
23shall not bill or otherwise attempt to recover from the
24employee the difference between the provider's charge and the
25amount paid by the employer or the insurer on a compensable
26injury, or for medical services or treatment determined by the

 

 

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

 

 

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

 

 

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

 

 

SB0904 Enrolled- 14 -LRB100 06276 SMS 16313 b

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

 

 

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1    determined to be complete but not paid or objected to
2    within 30 days shall be subject to interest pursuant to
3    item (3) of subsection (d) of Section 8.2.
4        (7) Provide that the Department of Insurance shall
5    impose an administrative fine if it determines that an
6    employer or insurer has failed to comply with the
7    electronic claims acceptance and response process. The
8    amount of the administrative fine shall be no greater than
9    $1,000 per each violation, but shall not exceed $10,000 for
10    identical violations during a calendar year.
11    (b) To the extent feasible, standards adopted pursuant to
12subdivision (a) shall be consistent with existing standards
13under the federal Health Insurance Portability and
14Accountability Act of 1996 and standards adopted under the
15Illinois Health Information Exchange and Technology Act.
16    (c) The rules requiring employers and insurers to accept
17electronic claims for payment of medical services shall be
18proposed on or before January 1, 2012, and shall require all
19employers and insurers to accept electronic claims for payment
20of medical services on or before June 30, 2012. The Director of
21Insurance shall adopt rules by January 1, 2019 to implement the
22changes to this Section made by this amendatory Act of the
23100th General Assembly. The Commission, with assistance from
24the Department and the Medical Fee Advisory Board, shall
25publish on its Internet website a companion guide to assist
26with compliance with electronic claims rules. The Medical Fee

 

 

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