HB0200 EnrolledLRB100 03450 JLS 13455 b

1    AN ACT concerning employment.
 
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 Section 8.2 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 directly. The employer shall make payment and
7providers shall submit bills and records in accordance with the
8provisions of this Section.
9        (1) All payments to providers for treatment provided
10    pursuant to this Act shall be made within 30 days of
11    receipt of the bills as long as the claim contains
12    substantially all the required data elements necessary to
13    adjudicate the bills.
14        (2) If the claim does not contain substantially all the
15    required data elements necessary to adjudicate the bill, or
16    the claim is denied for any other reason, in whole or in
17    part, the employer or insurer shall provide written
18    notification to the provider and to the employee or his or
19    her designee in the form of an explanation of benefits,
20    explaining the basis for the denial and describing any
21    additional necessary data elements, to the provider within
22    30 days of receipt of the bill.
23        (3) In the case of nonpayment to a provider within 30
24    days of receipt of the bill which contained substantially
25    all of the required data elements necessary to adjudicate
26    the bill or nonpayment to a provider of a portion of such a

 

 

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1    bill up to the lesser of the actual charge or the payment
2    level set by the Commission in the fee schedule established
3    in this Section, the bill, or portion of the bill, shall
4    incur interest at a rate of 1% per month payable to the
5    provider. Any required interest payments shall be made
6    within 30 days after payment.
7    (e) Except as provided in subsections (e-5), (e-10), and
8(e-15), a provider shall not hold an employee liable for costs
9related to a non-disputed procedure, treatment, or service
10rendered in connection with a compensable injury. The
11provisions of subsections (e-5), (e-10), (e-15), and (e-20)
12shall not apply if an employee provides information to the
13provider regarding participation in a group health plan. If the
14employee participates in a group health plan, the provider may
15submit a claim for services to the group health plan. If the
16claim for service is covered by the group health plan, the
17employee's responsibility shall be limited to applicable
18deductibles, co-payments, or co-insurance. Except as provided
19under subsections (e-5), (e-10), (e-15), and (e-20), a provider
20shall not bill or otherwise attempt to recover from the
21employee the difference between the provider's charge and the
22amount paid by the employer or the insurer on a compensable
23injury, or for medical services or treatment determined by the
24Commission to be excessive or unnecessary.
25    (e-5) If an employer notifies a provider that the employer
26does not consider the illness or injury to be compensable under

 

 

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1this Act, the provider may seek payment of the provider's
2actual charges from the employee for any procedure, treatment,
3or service rendered. Once an employee informs the provider that
4there is an application filed with the Commission to resolve a
5dispute over payment of such charges, the provider shall cease
6any and all efforts to collect payment for the services that
7are the subject of the dispute. Any statute of limitations or
8statute of repose applicable to the provider's efforts to
9collect payment from the employee shall be tolled from the date
10that the employee files the application with the Commission
11until the date that the provider is permitted to resume
12collection efforts under the provisions of this Section.
13    (e-10) If an employer notifies a provider that the employer
14will pay only a portion of a bill for any procedure, treatment,
15or service rendered in connection with a compensable illness or
16disease, the provider may seek payment from the employee for
17the remainder of the amount of the bill up to the lesser of the
18actual charge, negotiated rate, if applicable, or the payment
19level set by the Commission in the fee schedule established in
20this Section. Once an employee informs the provider that there
21is an application filed with the Commission to resolve a
22dispute over payment of such charges, the provider shall cease
23any and all efforts to collect payment for the services that
24are the subject of the dispute. Any statute of limitations or
25statute of repose applicable to the provider's efforts to
26collect payment from the employee shall be tolled from the date

 

 

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

 

 

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1the employee, a provider may resume any and all efforts to
2collect payment from the employee for the services rendered to
3the employee and the employee shall be responsible for payment
4of any outstanding bills for a procedure, treatment, or service
5rendered by a provider as well as the interest awarded under
6subsection (d) of this Section. In the case of a procedure,
7treatment, or service deemed compensable, the provider shall
8not require a payment rate, excluding the interest provisions
9under subsection (d), greater than the lesser of the actual
10charge or the payment level set by the Commission in the fee
11schedule established in this Section. Payment for services
12deemed not covered or not compensable under this Act is the
13responsibility of the employee unless a provider and employee
14have agreed otherwise in writing. Services not covered or not
15compensable under this Act are not subject to the fee schedule
16in this Section.
17    (f) Nothing in this Act shall prohibit an employer or
18insurer from contracting with a health care provider or group
19of health care providers for reimbursement levels for benefits
20under this Act different from those provided in this Section.
21    (g) On or before January 1, 2010 the Commission shall
22provide to the Governor and General Assembly a report regarding
23the implementation of the medical fee schedule and the index
24used for annual adjustment to that schedule as described in
25this Section.
26(Source: P.A. 97-18, eff. 6-28-11.)