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History of fee schedule developments

Illinois Workers' Compensation Commission

History of fee schedule developments

House Bill 2137 ordered the Commission to create fee schedules for treatment provided on or after February 1, 2006. Reimbursement is based on the site of treatment, e.g., if a treatment was provided in Chicago (Cook County), refer to the Region 1 fee schedule. See fee schedule regions

Payment should always be the lesser of the actual charge or the fee schedule amount. Section 8.2 of the Act states that the fee schedule sets the "maximum allowable payment;" Section 7110.90(d) of the Rules states, "The employer pays the lesser of the rate set forth in the (fee) schedule or the provider's actual charge." Parties are always free to contract for amounts different than the fee schedule rates.

A number of documents are part of the fee schedule: NCCI bundling edits, the Guide to Global Days, etc. See fee schedule documents

The fee schedule only sets the maximum reimbursement level. Note that it is utilization review, not the fee schedule, that may address whether a treatment is covered.

Each January 1, the fees are adjusted by the Consumer Price Index-U. Each year, the vendor, Ingenix/Optuminsight, posts the new fees online as soon as they are available. Usually, because the next year's procedure codes aren't finalized until late in the year, the fees are posted at the end of December.

When the fee schedule was first created in 2006, the data to calculate some fees were not available. By law, these procedures were set at 76% of the charged amount (POC76).

Effective February 1, 2009, the Commission, in consultation with the Workers' Compensation Medical Fee Advisory Board (WCMFAB), created new fee schedules for the following areas:

  • ambulatory surgical treatment centers;
  • hospital services;
  • outpatient radiology,
    • pathology,
    • laboratory,
    • physical medicine
    • rehabilitation services,
    • and surgical services
  • and rehabilitation hospitals.

On 6/30/09, the Commission converted the hospital inpatient fee schedule to the new MS-DRG coding system.

In November-December 2009, the Commission held seven seminars around the state and one statewide webinar to explain the fee schedule to payers and medical providers. View the PowerPoint presentation from the seminar.

We received hundreds of questions, and the discussion prompted the Commission, with the WCMFAB's input, to issue guidelines on three issues that came up the most.

HB2137 directed the Commission to report on the fee schedule's implementation by January 1, 2010. The Commission worked with the WCMFAB and others to draft the report. During this process, the participants started to form consensus on changes needed to make the fee schedule work better. Read the report to the General Assembly.

Following up on the issues in the General Assembly report, the Commission and WCMFAB agreed to change the reimbursement method for implants and to add accredited-but-not-licensed ambulatory surgical facilities to the ASTC fee schedule. Implant Information.

On June 28, 2011, Governor Quinn signed House Bill 1698(Public Act 97-18). Read a summary of the changes made by HB1698, including later rule updates as of 11/20/12. All fee schedule amounts were cut by 30%, effective September 1, 2011. The POC76 default was also cut by 30% so default payments are at 53.2% of charge (POC53.2).

From 2006-2012, fees were calculated for treatment at each of 29 geozips; effective 1/1/12, there are 14 hospital regions and 4 non-hospital regions. Fee Schedule Regions can be found here.

Effective March 27, 2012, to address an access-to-care problem, the Commission increased three rehabilitation hospital fee schedule amounts for the Rehabilitation Institute of Chicago. Section 8.2(b) of the Act authorizes the Commission to increase fee schedule amounts when it finds there is a significant limitation on injured workers' access to medical care.

A dental fee schedule took effect for treatment on or after June 20, 2012, eliminating the POC defaults.

Effective November 5, 2012, a rule took effect that clarified reimbursements for out-of-state treatment.

Effective November 20, 2012, the maximum reimbursement for repackaged drugs is the Average Wholesale Price for the underlying drug product, as identified by its National Drug Code from the original labeler.

On October 11, 2013, the Commission posted a new 2013 Professional Services fee schedule. As requested by business representatives and authorized by Section 8.2 of the Act, the Commission used non-Medicare Relative Value Units to ascribe dollar values to roughly 16,000 procedures that were POC53.2. Both payers and providers benefit from clear fee schedule amounts.

Effective for treatment on or after July 16, 2014, the Commission increased fee schedule amounts for some Evaluation and Management procedures (e.g., office visits). The 30% cut had brought some procedures below appropriate levels, creating an access-to-care problem. Earlier, the WCMFAB had voted unanimously to increase the rates.