103RD GENERAL ASSEMBLY
State of Illinois
2023 and 2024
HB4079

 

Introduced 5/10/2023, by Rep. Dan Ugaste

 

SYNOPSIS AS INTRODUCED:
 
820 ILCS 305/8.2

    Amends the Workers' Compensation Act. Provides that the Illinois Workers' Compensation Commission shall establish new medical fee schedules applicable on and after September 1, 2024 in accordance with specified criteria. Makes existing medical fee schedules inoperative after August 31, 2024. Provides that a provider may prescribe a one-time 7-day supply unless a prescription for more than 7 days is preauthorized by the employer. Provides for non-hospital fee schedules and hospital fee schedules applicable to different geographic areas of the State. Sets forth a procedure for petitioning the Commission if a maximum fee causes 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. Provides that by September 1, 2023, the Commission, in consultation with the Workers' Compensation Medical Fee Advisory Board, shall adopt by rule an evidence-based drug formulary and any rules necessary for its administration. Provides that prescriptions prescribed for workers' compensation cases shall be limited to the prescription drugs and doses on the closed formulary. Provides that a custom compound medication for longer than the one-time 7-day supply shall be approved for payment only if the compound meets specified standards. Provides for charges for custom compound medications. Effective immediately.


LRB103 32159 SPS 61248 b

 

 

A BILL FOR

 

HB4079LRB103 32159 SPS 61248 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
16hospital charges and fees as of August 1, 2004 but not earlier
17than August 1, 2002. These charges and fees are provider
18billed amounts and shall not include discounted charges. The
1980th percentile is the point on an ordered data set from low to
20high such that 80% of the cases are below or equal to that
21point and at most 20% are above or equal to that point. The
22Commission shall adjust these historical charges and fees as
23of August 1, 2004 by the Consumer Price Index-U for the period

 

 

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1August 1, 2004 through September 30, 2005. The Commission
2shall establish fee schedules for procedures, treatments, or
3services for hospital inpatient, hospital outpatient,
4emergency room and trauma, ambulatory surgical treatment
5centers, and professional services. These charges and fees
6shall be designated by geozip or any smaller geographic unit.
7The data shall in no way identify or tend to identify any
8patient, employer, or health care provider. As used in this
9Section, "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
17the geozip with up to 4 other geozips that are demographically
18and economically 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

 

 

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1that state's fee schedule amount or the fee schedule amount
2for the region in which the employee resides. If no fee
3schedule exists in that state, the provider shall be
4reimbursed at the lesser of the actual charge or the fee
5schedule amount for the region in which the employee resides.
6Not later than September 30 in 2006 and each year thereafter,
7the Commission shall automatically increase or decrease the
8maximum allowable payment for a procedure, treatment, or
9service established and in effect on January 1 of that year by
10the percentage change in the Consumer Price Index-U for the 12
11month period ending August 31 of that year. The increase or
12decrease shall become effective on January 1 of the following
13year. As used in this Section, "Consumer Price Index-U" means
14the index published by the Bureau of Labor Statistics of the
15U.S. Department of Labor, that measures the average change in
16prices of all goods and services purchased by all urban
17consumers, U.S. city average, all 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
11    forth in this Section, then the Commission shall average
12    or 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
15    than 9 charges or fees for a procedure, treatment,
16    product, supply, or service or where the fee schedule
17    amount cannot be determined by the non-discounted charge
18    data, 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
24    with 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
13    the 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-1.5) The following provisions apply to procedures,
4treatments, services, products, and supplies covered under
5this Act and rendered or to be rendered on or after September
61, 2024:
7        (1) In this Section:
8            "CPT code" means each Current Procedural
9        Terminology code, for each geographic region specified
10        in subsection (b) of this Section, included on the
11        most recent medical fee schedule established by the
12        Commission pursuant to this Section.
13            "DRG code" means each current diagnosis related
14        group code, for each geographic region specified in
15        subsection (b) of this Section, included on the most
16        recent medical fee schedule established by the
17        Commission pursuant to this Section.
18            "Geozip" means a three-digit zip code based on
19        data similarities, geographical similarities, and
20        frequencies.
21            "Health care services" means those CPT and DRG
22        codes for procedures, treatments, products, services,
23        or supplies for hospital inpatient, hospital
24        outpatient, emergency room, ambulatory surgical
25        treatment centers, accredited ambulatory surgical
26        treatment facilities, and professional services.

 

 

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1        "Health care services" does not include codes
2        classified as healthcare common procedure coding
3        systems or dental.
4            "Medicare maximum fee" means, for each CPT and DRG
5        code, the current maximum fee for that CPT or DRG code
6        allowed to be charged by the Centers for Medicare and
7        Medicaid Services for Medicare patients in that
8        geographic region. The Medicare maximum fee shall be
9        the greater of (i) the current maximum fee allowed to
10        be charged by the Centers for Medicare and Medicaid
11        Services for Medicare patients in the geographic
12        region or (ii) the maximum fee charged by the Centers
13        for Medicare and Medicaid Services for Medicare
14        patients in the geographic region on January 1, 2024.
15            "Medicare percentage amount" means, for each CPT
16        and DRG code, the workers' compensation maximum fee as
17        a percentage of the Medicare maximum fee.
18            "Workers' compensation maximum fee" means, for
19        each CPT and DRG code, the current maximum fee allowed
20        to be charged under the medical fee schedule
21        established by the Commission for that CPT or DRG code
22        in that geographic region.
23        (2) The Commission shall establish and maintain fee
24    schedules for procedures, treatments, products, services,
25    or supplies for hospital inpatient, hospital outpatient,
26    emergency room, ambulatory surgical treatment centers,

 

 

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1    accredited ambulatory surgical treatment facilities,
2    prescriptions filled and dispensed outside of a licensed
3    pharmacy, dental services, and professional services.
4    These fee schedule amounts shall be grouped into
5    geographic regions in the following manner:
6            (A) Four regions for non-hospital fee schedule
7        amounts shall be utilized:
8                (i) Cook County;
9                (ii) DuPage, Kane, Lake, and Will Counties;
10                (iii) Bond, Calhoun, Clinton, Jersey,
11            Macoupin, Madison, Monroe, Montgomery, Randolph,
12            St. Clair, and Washington Counties; and
13                (iv) all other counties of the State.
14            (B) Fourteen regions for hospital fee schedule
15        amounts shall be utilized:
16                (i) Cook, DuPage, Will, Kane, McHenry, DeKalb,
17            Kendall, and Grundy Counties;
18                (ii) Kankakee County;
19                (iii) Madison, St. Clair, Macoupin, Clinton,
20            Monroe, Jersey, Bond, and Calhoun Counties;
21                (iv) Winnebago and Boone Counties;
22                (v) Peoria, Tazewell, Woodford, Marshall, and
23            Stark Counties;
24                (vi) Champaign, Piatt, and Ford Counties;
25                (vii) Rock Island, Henry, and Mercer Counties;
26                (viii) Sangamon and Menard Counties;

 

 

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1                (ix) McLean County;
2                (x) Lake County;
3                (xi) Macon County;
4                (xii) Vermilion County;
5                (xiii) Alexander County; and
6                (xiv) all other counties of the State.
7            If a geozip overlaps into one or more of the
8        regions set forth in this subsection, then the
9        Commission shall average or repeat the charges and
10        fees in a geozip in order to designate charges and fees
11        for each region.
12        (3) The initial workers' compensation maximum fee for
13    each CPT and DRG code as of September 1, 2024 shall be
14    determined as follows:
15            (A) Within 45 days after the effective date of
16        this amendatory Act of the 103rd General Assembly, the
17        Commission shall determine the Medicare percentage
18        amount for each CPT and DRG code using the most recent
19        data available.
20            CPT or DRG codes which have a value, but are not
21        covered expenses under Medicare, are still compensable
22        under the medical fee schedule according to the rate
23        described in subparagraph (B).
24            (B) Within 30 days after the Commission makes the
25        determinations required under subparagraph (A), the
26        Commission shall determine an adjustment to be made to

 

 

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1        the workers' compensation maximum fee for each CPT and
2        DRG code as follows:
3                (i) if the Medicare percentage amount for that
4            CPT or DRG code is equal to or less than 125%, then
5            the workers' compensation maximum fee for that CPT
6            or DRG code shall be adjusted so that it equals
7            125% of the most recent Medicare maximum fee for
8            that CPT or DRG code;
9                (ii) if the Medicare percentage amount for
10            that CPT or DRG code is greater than 125% but less
11            than 150%, then the workers' compensation maximum
12            fee for that CPT or DRG code shall not be adjusted;
13                (iii) if the Medicare percentage amount for
14            that CPT or DRG code is greater than 150% but less
15            than or equal to 225%, then the workers'
16            compensation maximum fee for that CPT or DRG code
17            shall be adjusted so that it equals the greater of
18            (I) 150% of the most recent Medicare maximum fee
19            for that CPT or DRG code or (II) 85% of the most
20            recent workers' compensation maximum amount for
21            that CPT or DRG code;
22                (iv) if the Medicare percentage amount for
23            that CPT or DRG code is greater than 225% but less
24            than or equal to 428.57%, then the workers'
25            compensation maximum fee for that CPT or DRG code
26            shall be adjusted so that it equals the greater of

 

 

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1            (I) 191.25% of the most recent Medicare maximum
2            fee for that CPT or DRG code or (II) 70% of the
3            most recent workers' compensation maximum amount
4            for that CPT or DRG code; or
5                (v) if the Medicare percentage amount for that
6            CPT or DRG code is greater than 428.57%, then the
7            workers' compensation maximum fee for that CPT or
8            DRG code shall be adjusted so that it equals 300%
9            of the most recent Medicare maximum fee for that
10            CPT or DRG code.
11            The Commission shall promptly publish on its
12        website the adjustments determined pursuant to this
13        subparagraph (B).
14            (C) The initial workers' compensation maximum fee
15        for each CPT and DRG code as of September 1, 2024 shall
16        be equal to the workers' compensation maximum fee for
17        that code as determined and adjusted pursuant to
18        subparagraph (B), subject to any further adjustments
19        under paragraph (5) of this subsection.
20        (4) The Commission, as of September 1, 2025 and
21    September 1 of each year thereafter, shall adjust the
22    workers' compensation maximum fee for each CPT or DRG code
23    to exactly half of the most recent annual increase in the
24    Consumer Price Index-U.
25        (5) A person who believes that the workers'
26    compensation maximum fee for a CPT or DRG code, as

 

 

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1    otherwise determined pursuant to this subsection, creates
2    or would create upon implementation a significant
3    limitation on access to quality health care in either a
4    specific field of health care services or a specific
5    geographic limitation on access to health care may
6    petition the Commission to modify the workers'
7    compensation maximum fee for that CPT or DRG code so as to
8    not create that significant limitation.
9        The petitioner bears the burden of demonstrating, by a
10    preponderance of the credible evidence, that the workers'
11    compensation maximum fee that would otherwise apply would
12    create a significant limitation on access to quality
13    health care in either a specific field of health care
14    services or a specific geographic limitation on access to
15    health care. Petitions shall be made publicly available.
16    Such credible evidence shall include empirical data
17    demonstrating a significant limitation on access to
18    quality health care. Other interested persons may file
19    comments or responses to a petition within 30 days after
20    the filing of a petition.
21        The Commission shall take final action on each
22    petition within 180 days after filing. The Commission may,
23    but is not required to, seek the recommendation of the
24    Medical Fee Advisory Board to assist with this
25    determination. If the Commission grants the petition, the
26    Commission shall further increase the workers'

 

 

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1    compensation maximum fee for that CPT or DRG code by the
2    amount minimally necessary to avoid creating a significant
3    limitation on access to quality health care in either a
4    specific field of health care services or a specific
5    geographic limitation on access to health care. The
6    increased workers' compensation maximum fee shall take
7    effect upon entry of the Commission's final action.
8    (a-2) For procedures, treatments, services, or supplies
9covered under this Act and rendered or to be rendered on or
10after September 1, 2011, the maximum allowable payment shall
11be 70% of the fee schedule amounts, which shall be adjusted
12yearly by the Consumer Price Index-U, as described in
13subsection (a) of this Section.
14    (a-2.5) Subsections (a), (a-1), and (a-2) are inoperative
15on and after August 31, 2024.
16    (a-3) Prescriptions filled and dispensed outside of a
17licensed pharmacy shall be subject to a fee schedule that
18shall not exceed the Average Wholesale Price (AWP) plus a
19dispensing fee of $4.18. AWP or its equivalent as registered
20by the National Drug Code shall be set forth for that drug on
21that date as published in Medi-Span Medispan.
22    (a-3.5) By September 1, 2023, the Commission, in
23consultation with the Workers' Compensation Medical Fee
24Advisory Board, shall adopt by rule an evidence-based drug
25formulary and any rules necessary for its administration.
26Prescriptions prescribed for workers' compensation cases shall

 

 

HB4079- 15 -LRB103 32159 SPS 61248 b

1be limited to the prescription drugs and doses on the closed
2formulary.
3    A request for a prescription that is not on the closed
4formulary shall be reviewed under Section 8.7.
5    (a-4) As used in this Section, "custom compound
6medication" means a customized medication prescribed or
7ordered by a duly licensed prescriber for a specific patient
8that is prepared in a pharmacy by a licensed pharmacist in
9response to a licensed prescriber's prescription or order by
10combining, mixing, or altering of ingredients, but not
11reconstituting, to meet the unique needs of a specific
12patient.
13    (a-5) A custom compound medication for longer than the
14one-time 7-day supply described in subsection (a-6) shall be
15approved for payment only if the compound meets all of the
16following standards:
17        (1) there is no readily available commercially
18    manufactured equivalent product;
19        (2) no other Food and Drug Administration-approved
20    alternative drug is appropriate for the patient;
21        (3) the active ingredients of the compound each have a
22    National Drug Code number, are components of drugs
23    approved by the Food and Drug Administration, and the
24    active ingredients in the custom compound medication are
25    being used for diagnosis or conditions approved use by the
26    Food and Drug Administration and not being used for

 

 

HB4079- 16 -LRB103 32159 SPS 61248 b

1    off-label use;
2        (4) the drug has not been withdrawn or removed from
3    the market for safety reasons; and
4        (5) the prescriber is able to demonstrate to the payer
5    that the compound medication is clinically appropriate for
6    the intended use.
7    (a-6) Custom compound medications shall be charged using
8the specific amount of each component drug and its original
9manufacturer's National Drug Code number included in the
10compound. Charges shall be based on a maximum charge of the
11average wholesale price based upon the original manufacturer's
12National Drug Code number, as published by Red Book or
13Medi-Span and prorated for each component amount used. If the
14National Drug Code for the compound ingredient is a repackaged
15drug, the maximum allowable fee for the repackaged drug shall
16be determined by the National Drug Code and the average
17wholesale price of the underlying original manufacturer.
18Components without National Drug Code numbers shall not be
19charged. A single dispensing fee for a custom compound
20medication as determined by the Commission based on the actual
21costs of preparing and dispensing the custom compound
22medication shall be paid. The dispensing fee for a compound
23prescription shall be billed with code WC 700-C. The provider
24may prescribe a one-time 7-day supply. Any custom compound
25medication prescriptions for more than 7 days shall be
26preauthorized by the employer. Under all circumstances, if the

 

 

HB4079- 17 -LRB103 32159 SPS 61248 b

1compound medication meets the requirements in subsection
2(a-5), a 7-day supply shall be covered.
3    (a-7) This Section is subject to the other provisions of
4this Act, including, but not limited to, Section 8.7.
5    (b) Notwithstanding the provisions of subsection (a), if
6the Commission finds that there is a significant limitation on
7access to quality health care in either a specific field of
8health care services or a specific geographic limitation on
9access to health care, it may change the Consumer Price
10Index-U increase or decrease for that specific field or
11specific geographic limitation on access to health care to
12address that limitation.
13    (c) The Commission shall establish by rule a process to
14review those medical cases or outliers that involve
15extra-ordinary treatment to determine whether to make an
16additional adjustment to the maximum payment within a fee
17schedule for a procedure, treatment, or service.
18    (d) When a patient notifies a provider that the treatment,
19procedure, or service being sought is for a work-related
20illness or injury and furnishes the provider the name and
21address of the responsible employer, the provider shall bill
22the employer or its designee directly. The employer or its
23designee shall make payment for treatment in accordance with
24the provisions of this Section directly to the provider,
25except that, if a provider has designated a third-party
26billing entity to bill on its behalf, payment shall be made

 

 

HB4079- 18 -LRB103 32159 SPS 61248 b

1directly to the billing entity. Providers shall submit bills
2and records in accordance with the provisions of this Section.
3        (1) All payments to providers for treatment provided
4    pursuant to this Act shall be made within 30 days of
5    receipt of the bills as long as the bill contains
6    substantially all the required data elements necessary to
7    adjudicate the bill.
8        (2) If the bill does not contain substantially all the
9    required data elements necessary to adjudicate the bill,
10    or the claim is denied for any other reason, in whole or in
11    part, the employer or insurer shall provide written
12    notification to the provider in the form of an explanation
13    of benefits explaining the basis for the denial and
14    describing any additional necessary data elements within
15    30 days of receipt of the bill. The Commission, with
16    assistance from the Medical Fee Advisory Board, shall
17    adopt rules detailing the requirements for the explanation
18    of benefits required under this subsection.
19        (3) In the case (i) of nonpayment to a provider within
20    30 days of receipt of the bill which contained
21    substantially all of the required data elements necessary
22    to adjudicate the bill, (ii) of nonpayment to a provider
23    of a portion of such a bill, or (iii) where the provider
24    has not been issued an explanation of benefits for a bill,
25    the bill, or portion of the bill up to the lesser of the
26    actual charge or the payment level set by the Commission

 

 

HB4079- 19 -LRB103 32159 SPS 61248 b

1    in the fee schedule established in this Section, shall
2    incur interest at a rate of 1% per month payable by the
3    employer to the provider. Any required interest payments
4    shall be made by the employer or its insurer to the
5    provider within 30 days after payment of the bill.
6        (4) If the employer or its insurer fails to pay
7    interest within 30 days after payment of the bill as
8    required pursuant to paragraph (3), the provider may bring
9    an action in circuit court for the sole purpose of seeking
10    payment of interest pursuant to paragraph (3) against the
11    employer or its insurer responsible for insuring the
12    employer's liability pursuant to item (3) of subsection
13    (a) of Section 4. The circuit court's jurisdiction shall
14    be limited to enforcing payment of interest pursuant to
15    paragraph (3). Interest under paragraph (3) is only
16    payable to the provider. An employee is not responsible
17    for the payment of interest under this Section. The right
18    to interest under paragraph (3) shall not delay, diminish,
19    restrict, or alter in any way the benefits to which the
20    employee or his or her dependents are entitled under this
21    Act.
22    The changes made to this subsection (d) by this amendatory
23Act of the 100th General Assembly apply to procedures,
24treatments, and services rendered on and after the effective
25date of this amendatory Act of the 100th General Assembly.
26    (e) Except as provided in subsections (e-5), (e-10), and

 

 

HB4079- 20 -LRB103 32159 SPS 61248 b

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

 

 

HB4079- 21 -LRB103 32159 SPS 61248 b

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

 

 

HB4079- 22 -LRB103 32159 SPS 61248 b

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

 

 

HB4079- 23 -LRB103 32159 SPS 61248 b

1under subsection (d) of this Section. In the case of a
2procedure, treatment, or service deemed compensable, the
3provider shall not require a payment rate, excluding the
4interest provisions under subsection (d), greater than the
5lesser of the actual charge or the payment level set by the
6Commission in the fee schedule established in this Section.
7Payment for services deemed not covered or not compensable
8under this Act is the responsibility of the employee unless a
9provider and employee have agreed otherwise in writing.
10Services not covered or not compensable under this Act are not
11subject to the fee schedule in this Section.
12    (f) Nothing in this Act shall prohibit an employer or
13insurer from contracting with a health care provider or group
14of health care providers for reimbursement levels for benefits
15under this Act different from those provided in this Section.
16    (g) On or before January 1, 2010 the Commission shall
17provide to the Governor and General Assembly a report
18regarding the implementation of the medical fee schedule and
19the index used for annual adjustment to that schedule as
20described in this Section.
21(Source: P.A. 100-1117, eff. 11-27-18; 100-1175, eff.
221-11-19.)
 
23    Section 99. Effective date. This Act takes effect upon
24becoming law.