Sen. Michael E. Hastings

Filed: 11/13/2018

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 3452

2    AMENDMENT NO. ______. Amend House Bill 3452 by replacing
3everything after the enacting clause with the following:
 
4    "Section 5. If and only if Senate Bill 904 of the 100th
5General Assembly becomes law in the form in which it passed
6both houses on May 31, 2018, then the Workers' Compensation Act
7is amended by changing Section 8.2 as follows:
 
8    (820 ILCS 305/8.2)
9    Sec. 8.2. Fee schedule.
10    (a) Except as provided for in subsection (c), for
11procedures, treatments, or services covered under this Act and
12rendered or to be rendered on and after February 1, 2006, the
13maximum allowable payment shall be 90% of the 80th percentile
14of charges and fees as determined by the Commission utilizing
15information provided by employers' and insurers' national
16databases, with a minimum of 12,000,000 Illinois line item

 

 

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1charges and fees comprised of health care provider and hospital
2charges and fees as of August 1, 2004 but not earlier than
3August 1, 2002. These charges and fees are provider billed
4amounts and shall not include discounted charges. The 80th
5percentile is the point on an ordered data set from low to high
6such that 80% of the cases are below or equal to that point and
7at most 20% are above or equal to that point. The Commission
8shall adjust these historical charges and fees as of August 1,
92004 by the Consumer Price Index-U for the period August 1,
102004 through September 30, 2005. The Commission shall establish
11fee schedules for procedures, treatments, or services for
12hospital inpatient, hospital outpatient, emergency room and
13trauma, ambulatory surgical treatment centers, and
14professional services. These charges and fees shall be
15designated by geozip or any smaller geographic unit. The data
16shall in no way identify or tend to identify any patient,
17employer, or health care provider. As used in this Section,
18"geozip" means a three-digit zip code based on data
19similarities, geographical similarities, and frequencies. A
20geozip does not cross state boundaries. As used in this
21Section, "three-digit zip code" means a geographic area in
22which all zip codes have the same first 3 digits. If a geozip
23does not have the necessary number of charges and fees to
24calculate a valid percentile for a specific procedure,
25treatment, or service, the Commission may combine data from the
26geozip with up to 4 other geozips that are demographically and

 

 

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1economically similar and exhibit similarities in data and
2frequencies until the Commission reaches 9 charges or fees for
3that specific procedure, treatment, or service. In cases where
4the compiled data contains less than 9 charges or fees for a
5procedure, treatment, or service, reimbursement shall occur at
676% of charges and fees as determined by the Commission in a
7manner consistent with the provisions of this paragraph.
8Providers of out-of-state procedures, treatments, services,
9products, or supplies shall be reimbursed at the lesser of that
10state's fee schedule amount or the fee schedule amount for the
11region in which the employee resides. If no fee schedule exists
12in that state, the provider shall be reimbursed at the lesser
13of the actual charge or the fee schedule amount for the region
14in which the employee resides. Not later than September 30 in
152006 and each year thereafter, the Commission shall
16automatically increase or decrease the maximum allowable
17payment for a procedure, treatment, or service established and
18in effect on January 1 of that year by the percentage change in
19the Consumer Price Index-U for the 12 month period ending
20August 31 of that year. The increase or decrease shall become
21effective on January 1 of the following year. As used in this
22Section, "Consumer Price Index-U" means the index published by
23the Bureau of Labor Statistics of the U.S. Department of Labor,
24that measures the average change in prices of all goods and
25services purchased by all urban consumers, U.S. city average,
26all items, 1982-84=100.

 

 

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1    (a-1) Notwithstanding the provisions of subsection (a) and
2unless otherwise indicated, the following provisions shall
3apply to the medical fee schedule starting on September 1,
42011:
5        (1) The Commission shall establish and maintain fee
6    schedules for procedures, treatments, products, services,
7    or supplies for hospital inpatient, hospital outpatient,
8    emergency room, ambulatory surgical treatment centers,
9    accredited ambulatory surgical treatment facilities,
10    prescriptions filled and dispensed outside of a licensed
11    pharmacy, dental services, and professional services. This
12    fee schedule shall be based on the fee schedule amounts
13    already established by the Commission pursuant to
14    subsection (a) of this Section. However, starting on
15    January 1, 2012, these fee schedule amounts shall be
16    grouped into geographic regions in the following manner:
17            (A) Four regions for non-hospital fee schedule
18        amounts shall be utilized:
19                (i) Cook County;
20                (ii) DuPage, Kane, Lake, and Will Counties;
21                (iii) Bond, Calhoun, Clinton, Jersey,
22            Macoupin, Madison, Monroe, Montgomery, Randolph,
23            St. Clair, and Washington Counties; and
24                (iv) All other counties of the State.
25            (B) Fourteen regions for hospital fee schedule
26        amounts shall be utilized:

 

 

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

 

 

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

 

 

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1    (investigational devices); and 0636 (drugs requiring
2    detailed coding). Non-implantable devices or supplies
3    within these codes shall be reimbursed at 65% of actual
4    charge, which is the provider's normal rates under its
5    standard chargemaster. A standard chargemaster is the
6    provider's list of charges for procedures, treatments,
7    products, supplies, or services used to bill payers in a
8    consistent manner.
9        (6) The Commission shall automatically update all
10    codes and associated rules with the version of the codes
11    and rules valid on January 1 of that year.
12    (a-2) For procedures, treatments, services, or supplies
13covered under this Act and rendered or to be rendered on or
14after September 1, 2011, the maximum allowable payment shall be
1570% of the fee schedule amounts, which shall be adjusted yearly
16by the Consumer Price Index-U, as described in subsection (a)
17of this Section.
18    (a-3) Prescriptions filled and dispensed outside of a
19licensed pharmacy shall be subject to a fee schedule that shall
20not exceed the Average Wholesale Price (AWP) plus a dispensing
21fee of $4.18. AWP or its equivalent as registered by the
22National Drug Code shall be set forth for that drug on that
23date as published in Medispan.
24    (b) Notwithstanding the provisions of subsection (a), if
25the Commission finds that there is a significant limitation on
26access to quality health care in either a specific field of

 

 

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1health care services or a specific geographic limitation on
2access to health care, it may change the Consumer Price Index-U
3increase or decrease for that specific field or specific
4geographic limitation on access to health care to address that
5limitation.
6    (c) The Commission shall establish by rule a process to
7review those medical cases or outliers that involve
8extra-ordinary treatment to determine whether to make an
9additional adjustment to the maximum payment within a fee
10schedule for a procedure, treatment, or service.
11    (d) When a patient notifies a provider that the treatment,
12procedure, or service being sought is for a work-related
13illness or injury and furnishes the provider the name and
14address of the responsible employer, the provider shall bill
15the employer or its designee directly. The employer or its
16designee shall make payment for treatment in accordance with
17the provisions of this Section directly to the provider, except
18that, if a provider has designated a third-party billing entity
19to bill on its behalf, payment shall be made directly to the
20billing entity. Providers shall submit bills and records in
21accordance with the provisions of this Section.
22        (1) All payments to providers for treatment provided
23    pursuant to this Act shall be made within 30 days of
24    receipt of the bills as long as the bill contains
25    substantially all the required data elements necessary to
26    adjudicate the bill.

 

 

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

 

 

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1    required pursuant to paragraph (3) this subsection (d), the
2    provider may bring an action in circuit court for the sole
3    purpose of seeking payment of interest pursuant to
4    paragraph (3) enforce the provisions of this subsection (d)
5    against the employer or its insurer responsible for
6    insuring the employer's liability pursuant to item (3) of
7    subsection (a) of Section 4. The circuit court's
8    jurisdiction shall be limited to enforcing payment of
9    interest pursuant to paragraph (3). Interest under
10    paragraph (3) this subsection (d) is only payable to the
11    provider. An employee is not responsible for the payment of
12    interest under this Section. The right to interest under
13    paragraph (3) this subsection (d) shall not delay,
14    diminish, restrict, or alter in any way the benefits to
15    which the employee or his or her dependents are entitled
16    under this Act.
17    The changes made to this subsection (d) by this amendatory
18Act of the 100th General Assembly apply to procedures,
19treatments, and services rendered on and after the effective
20date of this amendatory Act of the 100th General Assembly.
21    (e) Except as provided in subsections (e-5), (e-10), and
22(e-15), a provider shall not hold an employee liable for costs
23related to a non-disputed procedure, treatment, or service
24rendered in connection with a compensable injury. The
25provisions of subsections (e-5), (e-10), (e-15), and (e-20)
26shall not apply if an employee provides information to the

 

 

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1provider regarding participation in a group health plan. If the
2employee participates in a group health plan, the provider may
3submit a claim for services to the group health plan. If the
4claim for service is covered by the group health plan, the
5employee's responsibility shall be limited to applicable
6deductibles, co-payments, or co-insurance. Except as provided
7under subsections (e-5), (e-10), (e-15), and (e-20), a provider
8shall not bill or otherwise attempt to recover from the
9employee the difference between the provider's charge and the
10amount paid by the employer or the insurer on a compensable
11injury, or for medical services or treatment determined by the
12Commission to be excessive or unnecessary.
13    (e-5) If an employer notifies a provider that the employer
14does not consider the illness or injury to be compensable under
15this Act, the provider may seek payment of the provider's
16actual charges from the employee for any procedure, treatment,
17or service rendered. Once an employee informs the provider that
18there is an application filed with the Commission to resolve a
19dispute over payment of such charges, the provider shall cease
20any and all efforts to collect payment for the services that
21are the subject of the dispute. Any statute of limitations or
22statute of repose applicable to the provider's efforts to
23collect payment from the employee shall be tolled from the date
24that the employee files the application with the Commission
25until the date that the provider is permitted to resume
26collection efforts under the provisions of this Section.

 

 

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

 

 

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1collection efforts under this Section. The reminders shall not
2be provided to any credit rating agency. The reminders may
3request that the employee furnish the provider with information
4about the proceeding under this Act, such as the file number,
5names of parties, and status of the case. If an employee fails
6to respond to such request for information or fails to furnish
7the information requested within 90 days of the date of the
8reminder, the provider is entitled to resume any and all
9efforts to collect payment from the employee for the services
10rendered to the employee and the employee shall be responsible
11for payment of any outstanding bills for a procedure,
12treatment, or service rendered by a provider.
13    (e-20) Upon a final award or judgment by an Arbitrator or
14the Commission, or a settlement agreed to by the employer and
15the employee, a provider may resume any and all efforts to
16collect payment from the employee for the services rendered to
17the employee and the employee shall be responsible for payment
18of any outstanding bills for a procedure, treatment, or service
19rendered by a provider as well as the interest awarded under
20subsection (d) of this Section. In the case of a procedure,
21treatment, or service deemed compensable, the provider shall
22not require a payment rate, excluding the interest provisions
23under subsection (d), greater than the lesser of the actual
24charge or the payment level set by the Commission in the fee
25schedule established in this Section. Payment for services
26deemed not covered or not compensable under this Act is the

 

 

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1responsibility of the employee unless a provider and employee
2have agreed otherwise in writing. Services not covered or not
3compensable under this Act are not subject to the fee schedule
4in this Section.
5    (f) Nothing in this Act shall prohibit an employer or
6insurer from contracting with a health care provider or group
7of health care providers for reimbursement levels for benefits
8under this Act different from those provided in this Section.
9    (g) On or before January 1, 2010 the Commission shall
10provide to the Governor and General Assembly a report regarding
11the implementation of the medical fee schedule and the index
12used for annual adjustment to that schedule as described in
13this Section.
14(Source: 10000SB0904enr.)
 
15    Section 99. Effective date. This Act takes effect upon
16becoming law or on the date Senate Bill 904 of the 100th
17General Assembly takes effect, whichever is later.".