Public Act 100-1117
 
SB0904 EnrolledLRB100 06276 SMS 16313 b

    AN ACT concerning regulation.
 
    Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
 
    Section 5. The Workers' Compensation Act is amended by
changing Sections 8.2 and 8.2a as follows:
 
    (820 ILCS 305/8.2)
    Sec. 8.2. Fee schedule.
    (a) Except as provided for in subsection (c), for
procedures, treatments, or services covered under this Act and
rendered or to be rendered on and after February 1, 2006, the
maximum allowable payment shall be 90% of the 80th percentile
of charges and fees as determined by the Commission utilizing
information provided by employers' and insurers' national
databases, with a minimum of 12,000,000 Illinois line item
charges and fees comprised of health care provider and hospital
charges and fees as of August 1, 2004 but not earlier than
August 1, 2002. These charges and fees are provider billed
amounts and shall not include discounted charges. The 80th
percentile is the point on an ordered data set from low to high
such that 80% of the cases are below or equal to that point and
at most 20% are above or equal to that point. The Commission
shall adjust these historical charges and fees as of August 1,
2004 by the Consumer Price Index-U for the period August 1,
2004 through September 30, 2005. The Commission shall establish
fee schedules for procedures, treatments, or services for
hospital inpatient, hospital outpatient, emergency room and
trauma, ambulatory surgical treatment centers, and
professional services. These charges and fees shall be
designated by geozip or any smaller geographic unit. The data
shall in no way identify or tend to identify any patient,
employer, or health care provider. As used in this Section,
"geozip" means a three-digit zip code based on data
similarities, geographical similarities, and frequencies. A
geozip does not cross state boundaries. As used in this
Section, "three-digit zip code" means a geographic area in
which all zip codes have the same first 3 digits. If a geozip
does not have the necessary number of charges and fees to
calculate a valid percentile for a specific procedure,
treatment, or service, the Commission may combine data from the
geozip with up to 4 other geozips that are demographically and
economically similar and exhibit similarities in data and
frequencies until the Commission reaches 9 charges or fees for
that specific procedure, treatment, or service. In cases where
the compiled data contains less than 9 charges or fees for a
procedure, treatment, or service, reimbursement shall occur at
76% of charges and fees as determined by the Commission in a
manner consistent with the provisions of this paragraph.
Providers of out-of-state procedures, treatments, services,
products, or supplies shall be reimbursed at the lesser of that
state's fee schedule amount or the fee schedule amount for the
region in which the employee resides. If no fee schedule exists
in that state, the provider shall be reimbursed at the lesser
of the actual charge or the fee schedule amount for the region
in which the employee resides. Not later than September 30 in
2006 and each year thereafter, the Commission shall
automatically increase or decrease the maximum allowable
payment for a procedure, treatment, or service established and
in effect on January 1 of that year by the percentage change in
the Consumer Price Index-U for the 12 month period ending
August 31 of that year. The increase or decrease shall become
effective on January 1 of the following year. As used in this
Section, "Consumer Price Index-U" means the index published by
the Bureau of Labor Statistics of the U.S. Department of Labor,
that measures the average change in prices of all goods and
services purchased by all urban consumers, U.S. city average,
all items, 1982-84=100.
    (a-1) Notwithstanding the provisions of subsection (a) and
unless otherwise indicated, the following provisions shall
apply to the medical fee schedule starting on September 1,
2011:
        (1) The Commission shall establish and maintain fee
    schedules for procedures, treatments, products, services,
    or supplies for hospital inpatient, hospital outpatient,
    emergency room, ambulatory surgical treatment centers,
    accredited ambulatory surgical treatment facilities,
    prescriptions filled and dispensed outside of a licensed
    pharmacy, dental services, and professional services. This
    fee schedule shall be based on the fee schedule amounts
    already established by the Commission pursuant to
    subsection (a) of this Section. However, starting on
    January 1, 2012, these fee schedule amounts shall be
    grouped into geographic regions in the following manner:
            (A) Four regions for non-hospital fee schedule
        amounts shall be utilized:
                (i) Cook County;
                (ii) DuPage, Kane, Lake, and Will Counties;
                (iii) Bond, Calhoun, Clinton, Jersey,
            Macoupin, Madison, Monroe, Montgomery, Randolph,
            St. Clair, and Washington Counties; and
                (iv) All other counties of the State.
            (B) Fourteen regions for hospital fee schedule
        amounts shall be utilized:
                (i) Cook, DuPage, Will, Kane, McHenry, DeKalb,
            Kendall, and Grundy Counties;
                (ii) Kankakee County;
                (iii) Madison, St. Clair, Macoupin, Clinton,
            Monroe, Jersey, Bond, and Calhoun Counties;
                (iv) Winnebago and Boone Counties;
                (v) Peoria, Tazewell, Woodford, Marshall, and
            Stark Counties;
                (vi) Champaign, Piatt, and Ford Counties;
                (vii) Rock Island, Henry, and Mercer Counties;
                (viii) Sangamon and Menard Counties;
                (ix) McLean County;
                (x) Lake County;
                (xi) Macon County;
                (xii) Vermilion County;
                (xiii) Alexander County; and
                (xiv) All other counties of the State.
        (2) If a geozip, as defined in subsection (a) of this
    Section, overlaps into one or more of the regions set forth
    in this Section, then the Commission shall average or
    repeat the charges and fees in a geozip in order to
    designate charges and fees for each region.
        (3) In cases where the compiled data contains less than
    9 charges or fees for a procedure, treatment, product,
    supply, or service or where the fee schedule amount cannot
    be determined by the non-discounted charge data,
    non-Medicare relative values and conversion factors
    derived from established fee schedule amounts, coding
    crosswalks, or other data as determined by the Commission,
    reimbursement shall occur at 76% of charges and fees until
    September 1, 2011 and 53.2% of charges and fees thereafter
    as determined by the Commission in a manner consistent with
    the provisions of this paragraph.
        (4) To establish additional fee schedule amounts, the
    Commission shall utilize provider non-discounted charge
    data, non-Medicare relative values and conversion factors
    derived from established fee schedule amounts, and coding
    crosswalks. The Commission may establish additional fee
    schedule amounts based on either the charge or cost of the
    procedure, treatment, product, supply, or service.
        (5) Implants shall be reimbursed at 25% above the net
    manufacturer's invoice price less rebates, plus actual
    reasonable and customary shipping charges whether or not
    the implant charge is submitted by a provider in
    conjunction with a bill for all other services associated
    with the implant, submitted by a provider on a separate
    claim form, submitted by a distributor, or submitted by the
    manufacturer of the implant. "Implants" include the
    following codes or any substantially similar updated code
    as determined by the Commission: 0274
    (prosthetics/orthotics); 0275 (pacemaker); 0276 (lens
    implant); 0278 (implants); 0540 and 0545 (ambulance); 0624
    (investigational devices); and 0636 (drugs requiring
    detailed coding). Non-implantable devices or supplies
    within these codes shall be reimbursed at 65% of actual
    charge, which is the provider's normal rates under its
    standard chargemaster. A standard chargemaster is the
    provider's list of charges for procedures, treatments,
    products, supplies, or services used to bill payers in a
    consistent manner.
        (6) The Commission shall automatically update all
    codes and associated rules with the version of the codes
    and rules valid on January 1 of that year.
    (a-2) For procedures, treatments, services, or supplies
covered under this Act and rendered or to be rendered on or
after September 1, 2011, the maximum allowable payment shall be
70% of the fee schedule amounts, which shall be adjusted yearly
by the Consumer Price Index-U, as described in subsection (a)
of this Section.
    (a-3) Prescriptions filled and dispensed outside of a
licensed pharmacy shall be subject to a fee schedule that shall
not exceed the Average Wholesale Price (AWP) plus a dispensing
fee of $4.18. AWP or its equivalent as registered by the
National Drug Code shall be set forth for that drug on that
date as published in Medispan.
    (b) Notwithstanding the provisions of subsection (a), if
the Commission finds that there is a significant limitation on
access to quality health care in either a specific field of
health care services or a specific geographic limitation on
access to health care, it may change the Consumer Price Index-U
increase or decrease for that specific field or specific
geographic limitation on access to health care to address that
limitation.
    (c) The Commission shall establish by rule a process to
review those medical cases or outliers that involve
extra-ordinary treatment to determine whether to make an
additional adjustment to the maximum payment within a fee
schedule for a procedure, treatment, or service.
    (d) When a patient notifies a provider that the treatment,
procedure, or service being sought is for a work-related
illness or injury and furnishes the provider the name and
address of the responsible employer, the provider shall bill
the employer or its designee directly. The employer or its
designee shall make payment for treatment in accordance with
the provisions of this Section directly to the provider, except
that, if a provider has designated a third-party billing entity
to bill on its behalf, payment shall be made directly to the
billing entity. Providers and providers shall submit bills and
records in accordance with the provisions of this Section.
        (1) All payments to providers for treatment provided
    pursuant to this Act shall be made within 30 days of
    receipt of the bills as long as the bill claim contains
    substantially all the required data elements necessary to
    adjudicate the bill bills.
        (2) If the bill claim does not contain substantially
    all the required data elements necessary to adjudicate the
    bill, or the claim is denied for any other reason, in whole
    or in part, the employer or insurer shall provide written
    notification to the provider in the form of an explanation
    of benefits , explaining the basis for the denial and
    describing any additional necessary data elements, to the
    provider within 30 days of receipt of the bill. The
    Commission, with assistance from the Medical Fee Advisory
    Board, shall adopt rules detailing the requirements for the
    explanation of benefits required under this subsection.
        (3) In the case (i) of nonpayment to a provider within
    30 days of receipt of the bill which contained
    substantially all of the required data elements necessary
    to adjudicate the bill, (ii) of or nonpayment to a provider
    of a portion of such a bill, or (iii) where the provider
    has not been issued an explanation of benefits for a bill
    up to the lesser of the actual charge or the payment level
    set by the Commission in the fee schedule established in
    this Section, the bill, or portion of the bill up to the
    lesser of the actual charge or the payment level set by the
    Commission in the fee schedule established in this Section,
    shall incur interest at a rate of 1% per month payable by
    the employer to the provider. Any required interest
    payments shall be made by the employer or its insurer to
    the provider not later than within 30 days after payment of
    the bill.
        (4) If the employer or its insurer fails to pay
    interest required pursuant to this subsection (d), the
    provider may bring an action in circuit court to enforce
    the provisions of this subsection (d) against the employer
    or its insurer responsible for insuring the employer's
    liability pursuant to item (3) of subsection (a) of Section
    4. Interest under this subsection (d) is only payable to
    the provider. An employee is not responsible for the
    payment of interest under this Section. The right to
    interest under this subsection (d) shall not delay,
    diminish, restrict, or alter in any way the benefits to
    which the employee or his or her dependents are entitled
    under this Act.
    The changes made to this subsection (d) by this amendatory
Act of the 100th General Assembly apply to procedures,
treatments, and services rendered on and after the effective
date of this amendatory Act of the 100th General Assembly.
    (e) Except as provided in subsections (e-5), (e-10), and
(e-15), a provider shall not hold an employee liable for costs
related to a non-disputed procedure, treatment, or service
rendered in connection with a compensable injury. The
provisions of subsections (e-5), (e-10), (e-15), and (e-20)
shall not apply if an employee provides information to the
provider regarding participation in a group health plan. If the
employee participates in a group health plan, the provider may
submit a claim for services to the group health plan. If the
claim for service is covered by the group health plan, the
employee's responsibility shall be limited to applicable
deductibles, co-payments, or co-insurance. Except as provided
under subsections (e-5), (e-10), (e-15), and (e-20), a provider
shall not bill or otherwise attempt to recover from the
employee the difference between the provider's charge and the
amount paid by the employer or the insurer on a compensable
injury, or for medical services or treatment determined by the
Commission to be excessive or unnecessary.
    (e-5) If an employer notifies a provider that the employer
does not consider the illness or injury to be compensable under
this Act, the provider may seek payment of the provider's
actual charges from the employee for any procedure, treatment,
or service rendered. Once an employee informs the provider that
there is an application filed with the Commission to resolve a
dispute over payment of such charges, the provider shall cease
any and all efforts to collect payment for the services that
are the subject of the dispute. Any statute of limitations or
statute of repose applicable to the provider's efforts to
collect payment from the employee shall be tolled from the date
that the employee files the application with the Commission
until the date that the provider is permitted to resume
collection efforts under the provisions of this Section.
    (e-10) If an employer notifies a provider that the employer
will pay only a portion of a bill for any procedure, treatment,
or service rendered in connection with a compensable illness or
disease, the provider may seek payment from the employee for
the remainder of the amount of the bill up to the lesser of the
actual charge, negotiated rate, if applicable, or the payment
level set by the Commission in the fee schedule established in
this Section. Once an employee informs the provider that there
is an application filed with the Commission to resolve a
dispute over payment of such charges, the provider shall cease
any and all efforts to collect payment for the services that
are the subject of the dispute. Any statute of limitations or
statute of repose applicable to the provider's efforts to
collect payment from the employee shall be tolled from the date
that the employee files the application with the Commission
until the date that the provider is permitted to resume
collection efforts under the provisions of this Section.
    (e-15) When there is a dispute over the compensability of
or amount of payment for a procedure, treatment, or service,
and a case is pending or proceeding before an Arbitrator or the
Commission, the provider may mail the employee reminders that
the employee will be responsible for payment of any procedure,
treatment or service rendered by the provider. The reminders
must state that they are not bills, to the extent practicable
include itemized information, and state that the employee need
not pay until such time as the provider is permitted to resume
collection efforts under this Section. The reminders shall not
be provided to any credit rating agency. The reminders may
request that the employee furnish the provider with information
about the proceeding under this Act, such as the file number,
names of parties, and status of the case. If an employee fails
to respond to such request for information or fails to furnish
the information requested within 90 days of the date of the
reminder, the provider is entitled to resume any and all
efforts to collect payment from the employee for the services
rendered to the employee and the employee shall be responsible
for payment of any outstanding bills for a procedure,
treatment, or service rendered by a provider.
    (e-20) Upon a final award or judgment by an Arbitrator or
the Commission, or a settlement agreed to by the employer and
the employee, a provider may resume any and all efforts to
collect payment from the employee for the services rendered to
the employee and the employee shall be responsible for payment
of any outstanding bills for a procedure, treatment, or service
rendered by a provider as well as the interest awarded under
subsection (d) of this Section. In the case of a procedure,
treatment, or service deemed compensable, the provider shall
not require a payment rate, excluding the interest provisions
under subsection (d), greater than the lesser of the actual
charge or the payment level set by the Commission in the fee
schedule established in this Section. Payment for services
deemed not covered or not compensable under this Act is the
responsibility of the employee unless a provider and employee
have agreed otherwise in writing. Services not covered or not
compensable under this Act are not subject to the fee schedule
in this Section.
    (f) Nothing in this Act shall prohibit an employer or
insurer from contracting with a health care provider or group
of health care providers for reimbursement levels for benefits
under this Act different from those provided in this Section.
    (g) On or before January 1, 2010 the Commission shall
provide to the Governor and General Assembly a report regarding
the implementation of the medical fee schedule and the index
used for annual adjustment to that schedule as described in
this Section.
(Source: P.A. 97-18, eff. 6-28-11.)
 
    (820 ILCS 305/8.2a)
    Sec. 8.2a. Electronic claims.
    (a) The Director of Insurance shall adopt rules to do all
of the following:
        (1) Ensure that all health care providers and
    facilities submit medical bills for payment on
    standardized forms.
        (2) Require acceptance by employers and insurers of
    electronic claims for payment of medical services.
        (3) Ensure confidentiality of medical information
    submitted on electronic claims for payment of medical
    services.
        (4) Ensure that health care providers have an
    opportunity to comply with requests for records by
    employers and insurers for the authorization of the payment
    of workers' compensation claims.
        (5) Ensure that health care providers are responsible
    for supplying only those medical records pertaining to the
    provider's own claims that are minimally necessary under
    the federal Health Insurance Portability and
    Accountability Act of 1996.
        (6) Provide that any electronically submitted bill
    determined to be complete but not paid or objected to
    within 30 days shall be subject to interest pursuant to
    item (3) of subsection (d) of Section 8.2.
        (7) Provide that the Department of Insurance shall
    impose an administrative fine if it determines that an
    employer or insurer has failed to comply with the
    electronic claims acceptance and response process. The
    amount of the administrative fine shall be no greater than
    $1,000 per each violation, but shall not exceed $10,000 for
    identical violations during a calendar year.
    (b) To the extent feasible, standards adopted pursuant to
subdivision (a) shall be consistent with existing standards
under the federal Health Insurance Portability and
Accountability Act of 1996 and standards adopted under the
Illinois Health Information Exchange and Technology Act.
    (c) The rules requiring employers and insurers to accept
electronic claims for payment of medical services shall be
proposed on or before January 1, 2012, and shall require all
employers and insurers to accept electronic claims for payment
of medical services on or before June 30, 2012. The Director of
Insurance shall adopt rules by January 1, 2019 to implement the
changes to this Section made by this amendatory Act of the
100th General Assembly. The Commission, with assistance from
the Department and the Medical Fee Advisory Board, shall
publish on its Internet website a companion guide to assist
with compliance with electronic claims rules. The Medical Fee
Advisory Board shall periodically review the companion guide.
    (d) The Director of Insurance shall by rule establish
criteria for granting exceptions to employers, insurance
carriers, and health care providers who are unable to submit or
accept medical bills electronically.
(Source: P.A. 97-18, eff. 6-28-11.)
 
    Section 99. Effective date. This Act takes effect upon
becoming law.