Rep. Michael J. Madigan

Filed: 5/21/2015

 

 


 

 


 
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1
AMENDMENT TO HOUSE BILL 1287

2    AMENDMENT NO. ______. Amend House Bill 1287, AS AMENDED, by
3inserting the following in its proper numeric sequence in the
4bill:
 
5    "Section 15. The Workers' Compensation Act is amended by
6changing Section 8.2 as follows:
 
7    (820 ILCS 305/8.2)
8    Sec. 8.2. Fee schedule.
9    (a) Except as provided for in subsection (c), for
10procedures, treatments, or services covered under this Act and
11rendered or to be rendered on and after February 1, 2006, the
12maximum allowable payment shall be 90% of the 80th percentile
13of charges and fees as determined by the Commission utilizing
14information provided by employers' and insurers' national
15databases, with a minimum of 12,000,000 Illinois line item
16charges and fees comprised of health care provider and hospital

 

 

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1charges and fees as of August 1, 2004 but not earlier than
2August 1, 2002. These charges and fees are provider billed
3amounts and shall not include discounted charges. The 80th
4percentile is the point on an ordered data set from low to high
5such that 80% of the cases are below or equal to that point and
6at most 20% are above or equal to that point. The Commission
7shall adjust these historical charges and fees as of August 1,
82004 by the Consumer Price Index-U for the period August 1,
92004 through September 30, 2005. The Commission shall establish
10fee schedules for procedures, treatments, or services for
11hospital inpatient, hospital outpatient, emergency room and
12trauma, ambulatory surgical treatment centers, and
13professional services. These charges and fees shall be
14designated by geozip or any smaller geographic unit. The data
15shall in no way identify or tend to identify any patient,
16employer, or health care provider. As used in this Section,
17"geozip" means a three-digit zip code based on data
18similarities, geographical similarities, and frequencies. A
19geozip does not cross state boundaries. As used in this
20Section, "three-digit zip code" means a geographic area in
21which all zip codes have the same first 3 digits. If a geozip
22does not have the necessary number of charges and fees to
23calculate a valid percentile for a specific procedure,
24treatment, or service, the Commission may combine data from the
25geozip with up to 4 other geozips that are demographically and
26economically similar and exhibit similarities in data and

 

 

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1frequencies until the Commission reaches 9 charges or fees for
2that specific procedure, treatment, or service. In cases where
3the compiled data contains less than 9 charges or fees for a
4procedure, treatment, or service, reimbursement shall occur at
576% of charges and fees as determined by the Commission in a
6manner consistent with the provisions of this paragraph.
7Providers of out-of-state procedures, treatments, services,
8products, or supplies shall be reimbursed at the lesser of that
9state's fee schedule amount or the fee schedule amount for the
10region in which the employee resides. If no fee schedule exists
11in that state, the provider shall be reimbursed at the lesser
12of the actual charge or the fee schedule amount for the region
13in which the employee resides. Not later than September 30 in
142006 and each year thereafter, the Commission shall
15automatically increase or decrease the maximum allowable
16payment for a procedure, treatment, or service established and
17in effect on January 1 of that year by the percentage change in
18the Consumer Price Index-U for the 12 month period ending
19August 31 of that year. The increase or decrease shall become
20effective on January 1 of the following year. As used in this
21Section, "Consumer Price Index-U" means the index published by
22the Bureau of Labor Statistics of the U.S. Department of Labor,
23that measures the average change in prices of all goods and
24services purchased by all urban consumers, U.S. city average,
25all items, 1982-84=100.
26    (a-1) Notwithstanding the provisions of subsection (a) and

 

 

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1unless otherwise indicated, the following provisions shall
2apply to the medical fee schedule starting on September 1,
32011:
4        (1) The Commission shall establish and maintain fee
5    schedules for procedures, treatments, products, services,
6    or supplies for hospital inpatient, hospital outpatient,
7    emergency room, ambulatory surgical treatment centers,
8    accredited ambulatory surgical treatment facilities,
9    prescriptions filled and dispensed outside of a licensed
10    pharmacy, dental services, and professional services. This
11    fee schedule shall be based on the fee schedule amounts
12    already established by the Commission pursuant to
13    subsection (a) of this Section. However, starting on
14    January 1, 2012, these fee schedule amounts shall be
15    grouped into geographic regions in the following manner:
16            (A) Four regions for non-hospital fee schedule
17        amounts shall be utilized:
18                (i) Cook County;
19                (ii) DuPage, Kane, Lake, and Will Counties;
20                (iii) Bond, Calhoun, Clinton, Jersey,
21            Macoupin, Madison, Monroe, Montgomery, Randolph,
22            St. Clair, and Washington Counties; and
23                (iv) All other counties of the State.
24            (B) Fourteen regions for hospital fee schedule
25        amounts shall be utilized:
26                (i) Cook, DuPage, Will, Kane, McHenry, DeKalb,

 

 

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

 

 

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1    derived from established fee schedule amounts, coding
2    crosswalks, or other data as determined by the Commission,
3    reimbursement shall occur at 76% of charges and fees until
4    September 1, 2011 and 53.2% of charges and fees until
5    September 1, 2015 thereafter as determined by the
6    Commission in a manner consistent with the provisions of
7    this paragraph. On and after September 1, 2015,
8    reimbursement shall occur at 37.24% of charges and fees as
9    determined by the Commission in a manner consistent with
10    the provisions of this paragraph.
11        (4) To establish additional fee schedule amounts, the
12    Commission shall utilize provider non-discounted charge
13    data, non-Medicare relative values and conversion factors
14    derived from established fee schedule amounts, and coding
15    crosswalks. The Commission may establish additional fee
16    schedule amounts based on either the charge or cost of the
17    procedure, treatment, product, supply, or service.
18        (5) Implants shall be reimbursed at 25% above the net
19    manufacturer's invoice price less rebates, plus actual
20    reasonable and customary shipping charges whether or not
21    the implant charge is submitted by a provider in
22    conjunction with a bill for all other services associated
23    with the implant, submitted by a provider on a separate
24    claim form, submitted by a distributor, or submitted by the
25    manufacturer of the implant. "Implants" include the
26    following codes or any substantially similar updated code

 

 

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1    as determined by the Commission: 0274
2    (prosthetics/orthotics); 0275 (pacemaker); 0276 (lens
3    implant); 0278 (implants); 0540 and 0545 (ambulance); 0624
4    (investigational devices); and 0636 (drugs requiring
5    detailed coding). Non-implantable devices or supplies
6    within these codes shall be reimbursed at 65% of actual
7    charge, which is the provider's normal rates under its
8    standard chargemaster. A standard chargemaster is the
9    provider's list of charges for procedures, treatments,
10    products, supplies, or services used to bill payers in a
11    consistent manner.
12        (6) The Commission shall automatically update all
13    codes and associated rules with the version of the codes
14    and rules valid on January 1 of that year.
15    (a-2) For procedures, treatments, services, or supplies
16covered under this Act and rendered or to be rendered on or
17after September 1, 2011, the maximum allowable payment shall be
1870% of the fee schedule amounts, which shall be adjusted yearly
19by the Consumer Price Index-U, as described in subsection (a)
20of this Section.
21    (a-2.5) For procedures, treatments, services, or supplies
22covered under this Act and rendered or to be rendered on or
23after September 1, 2015, the maximum allowable payment shall be
2440% of the fee schedule amount, which shall be adjusted yearly
25by the Consumer Price Index-U, as described in subsection (a)
26of this Section. This shall not apply to any procedure,

 

 

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1treatment, or service classified by an evaluation and
2management code or a physical medicine code on the fee
3schedule.
4    (a-3) Prescriptions filled and dispensed outside of a
5licensed pharmacy shall be subject to a fee schedule that shall
6not exceed the Average Wholesale Price (AWP) plus a dispensing
7fee of $4.18. AWP or its equivalent as registered by the
8National Drug Code shall be set forth for that drug on that
9date as published in Medispan.
10    (b) Notwithstanding the provisions of subsection (a), if
11the Commission finds that there is a significant limitation on
12access to quality health care in either a specific field of
13health care services or a specific geographic limitation on
14access to health care, it may change the Consumer Price Index-U
15increase or decrease for that specific field or specific
16geographic limitation on access to health care to address that
17limitation.
18    (c) The Commission shall establish by rule a process to
19review those medical cases or outliers that involve
20extra-ordinary treatment to determine whether to make an
21additional adjustment to the maximum payment within a fee
22schedule for a procedure, treatment, or service.
23    (d) When a patient notifies a provider that the treatment,
24procedure, or service being sought is for a work-related
25illness or injury and furnishes the provider the name and
26address of the responsible employer, the provider shall bill

 

 

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1the employer directly. The employer shall make payment and
2providers shall submit bills and records in accordance with the
3provisions of this Section.
4        (1) All payments to providers for treatment provided
5    pursuant to this Act shall be made within 30 days of
6    receipt of the bills as long as the claim contains
7    substantially all the required data elements necessary to
8    adjudicate the bills.
9        (2) If the claim does not contain substantially all the
10    required data elements necessary to adjudicate the bill, or
11    the claim is denied for any other reason, in whole or in
12    part, the employer or insurer shall provide written
13    notification, explaining the basis for the denial and
14    describing any additional necessary data elements, to the
15    provider within 30 days of receipt of the bill.
16        (3) In the case of nonpayment to a provider within 30
17    days of receipt of the bill which contained substantially
18    all of the required data elements necessary to adjudicate
19    the bill or nonpayment to a provider of a portion of such a
20    bill up to the lesser of the actual charge or the payment
21    level set by the Commission in the fee schedule established
22    in this Section, the bill, or portion of the bill, shall
23    incur interest at a rate of 1% per month payable to the
24    provider. Any required interest payments shall be made
25    within 30 days after payment.
26    (e) Except as provided in subsections (e-5), (e-10), and

 

 

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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 the
7employee participates in a group health plan, the provider may
8submit a claim for services to the group health plan. If the
9claim 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 provider
13shall not bill or otherwise attempt to recover from the
14employee the difference between the provider's charge and the
15amount 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 under
20this Act, the provider may seek payment of the provider's
21actual charges from the employee for any procedure, treatment,
22or service rendered. Once an employee informs the provider that
23there is an application filed with the Commission to resolve a
24dispute over payment of such charges, the provider shall cease
25any and all efforts to collect payment for the services that
26are the subject of the dispute. Any statute of limitations or

 

 

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

 

 

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

 

 

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