HB3452 EnrolledLRB100 05727 SMS 15749 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. 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
17charges and fees comprised of health care provider and hospital
18charges and fees as of August 1, 2004 but not earlier than
19August 1, 2002. These charges and fees are provider billed
20amounts and shall not include discounted charges. The 80th
21percentile is the point on an ordered data set from low to high
22such that 80% of the cases are below or equal to that point and
23at most 20% are above or equal to that point. The Commission

 

 

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1shall adjust these historical charges and fees as of August 1,
22004 by the Consumer Price Index-U for the period August 1,
32004 through September 30, 2005. The Commission shall establish
4fee schedules for procedures, treatments, or services for
5hospital inpatient, hospital outpatient, emergency room and
6trauma, ambulatory surgical treatment centers, and
7professional services. These charges and fees shall be
8designated by geozip or any smaller geographic unit. The data
9shall in no way identify or tend to identify any patient,
10employer, or health care provider. As used in this Section,
11"geozip" means a three-digit zip code based on data
12similarities, geographical similarities, and frequencies. A
13geozip does not cross state boundaries. As used in this
14Section, "three-digit zip code" means a geographic area in
15which all zip codes have the same first 3 digits. If a geozip
16does not have the necessary number of charges and fees to
17calculate a valid percentile for a specific procedure,
18treatment, or service, the Commission may combine data from the
19geozip with up to 4 other geozips that are demographically and
20economically similar and exhibit similarities in data and
21frequencies until the Commission reaches 9 charges or fees for
22that specific procedure, treatment, or service. In cases where
23the compiled data contains less than 9 charges or fees for a
24procedure, treatment, or service, reimbursement shall occur at
2576% of charges and fees as determined by the Commission in a
26manner consistent with the provisions of this paragraph.

 

 

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1Providers of out-of-state procedures, treatments, services,
2products, or supplies shall be reimbursed at the lesser of that
3state's fee schedule amount or the fee schedule amount for the
4region in which the employee resides. If no fee schedule exists
5in that state, the provider shall be reimbursed at the lesser
6of the actual charge or the fee schedule amount for the region
7in which the employee resides. Not later than September 30 in
82006 and each year thereafter, the Commission shall
9automatically increase or decrease the maximum allowable
10payment for a procedure, treatment, or service established and
11in effect on January 1 of that year by the percentage change in
12the Consumer Price Index-U for the 12 month period ending
13August 31 of that year. The increase or decrease shall become
14effective on January 1 of the following year. As used in this
15Section, "Consumer Price Index-U" means the index published by
16the Bureau of Labor Statistics of the U.S. Department of Labor,
17that measures the average change in prices of all goods and
18services purchased by all urban consumers, U.S. city average,
19all items, 1982-84=100.
20    (a-1) Notwithstanding the provisions of subsection (a) and
21unless otherwise indicated, the following provisions shall
22apply to the medical fee schedule starting on September 1,
232011:
24        (1) The Commission shall establish and maintain fee
25    schedules for procedures, treatments, products, services,
26    or supplies for hospital inpatient, hospital outpatient,

 

 

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

 

 

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

 

 

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

 

 

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1    consistent manner.
2        (6) The Commission shall automatically update all
3    codes and associated rules with the version of the codes
4    and rules valid on January 1 of that year.
5    (a-2) For procedures, treatments, services, or supplies
6covered under this Act and rendered or to be rendered on or
7after September 1, 2011, the maximum allowable payment shall be
870% of the fee schedule amounts, which shall be adjusted yearly
9by the Consumer Price Index-U, as described in subsection (a)
10of this Section.
11    (a-3) Prescriptions filled and dispensed outside of a
12licensed pharmacy shall be subject to a fee schedule that shall
13not exceed the Average Wholesale Price (AWP) plus a dispensing
14fee of $4.18. AWP or its equivalent as registered by the
15National Drug Code shall be set forth for that drug on that
16date as published in Medispan.
17    (b) Notwithstanding the provisions of subsection (a), if
18the Commission finds that there is a significant limitation on
19access to quality health care in either a specific field of
20health care services or a specific geographic limitation on
21access to health care, it may change the Consumer Price Index-U
22increase or decrease for that specific field or specific
23geographic limitation on access to health care to address that
24limitation.
25    (c) The Commission shall establish by rule a process to
26review those medical cases or outliers that involve

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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

 

 

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1under this Act different from those provided in this Section.
2    (g) On or before January 1, 2010 the Commission shall
3provide to the Governor and General Assembly a report regarding
4the implementation of the medical fee schedule and the index
5used for annual adjustment to that schedule as described in
6this Section.
7(Source: 10000SB0904enr.)
 
8    Section 99. Effective date. This Act takes effect upon
9becoming law or on the date Senate Bill 904 of the 100th
10General Assembly takes effect, whichever is later.