Medical Fee Schedule

What is included in global fee schedules?

The Hospital Inpatient, Hospital Outpatient Surgical, and Ambulatory Surgery Center facility fee schedules are all global fee schedules. Generally, they cover all facility fees except for the carve-outs (e.g, implants). This includes but is not limited to supplies, miscellaneous services, etc. Providers and payers are expected to follow common conventions as to what is understood to be included.

What facilities are covered under the Ambulatory Surgical Treatment Center/Facility (ASTC) fee schedule?

Effective 9/1/11, facilities that are either licensed or accredited are included in the ASTC fee schedule.

The Illinois Department of Public Health maintains a list of licensed ASTCS. It is our understanding that unlicensed but accredited facilities often initially send in a bill and include a certificate, showing the expiration date of the accreditation, and then the payer will keep track of the certificates. Alternately, payers can ask the provider for proof or search the organizations' websites: AAAASF; AAAHC; JCAHO .

If anesthesia is given for only part of a 15-minute increment, how should this be billed?

The standard practice is to round up to the next unit. If anesthesia was administered for 7 minutes, for example, you would bill one unit. If anesthesia is administered for 63 minutes, five units would be billed, etc.

How should CRNAs and MD Supervisors be paid for anesthesia services?

The IWCC has taken the position that what represents one full payment for a service should be made for professional anesthesia services. This issue is more easily managed when both a CRNA and MD supervisor are part of the same practice and share the same tax ID. Apparently, we have situations where the supervising MD is billing for services with his or her own tax ID, and the hospital is billing for the staff CRNA services with the hospital’s tax ID. Professional services are paid at POC76/53.2 for hospital professional, and per the professional services fee schedule for the MD.

There is not a binding regulation on this point, but the Commission recommends that the MD supervisor receive 100% of the amount allowed under the fee schedule, and then he or she should pay the CRNA, based on the arrangements between the MD and the hospital.

How should dental services be paid?

For treatment between 2/1/06 - 8/31/11, bills should be paid at 76% of the charged amount (POC76).

For treatment from 9/1/11 - 6/19/12, bills should be paid at 53.2% of the charged amount (POC53.2).

For treatment on or after 6/20/12, bills should be paid at the lesser of the actual charge or the fee schedule amount. There is one statewide dental fee schedule.

Parties are always free to contract for amounts different from the fee schedule.

How should prescription drugs be paid?

Before 6/28/11, all prescriptions were paid at the usual and customary (U&C) rate. Our regulations do not define U&C. If there is a dispute, the parties would take the issue before an arbitrator.

Effective 6/28/11 (Section 8.2(a-3) of the Act), each prescription filled and dispensed outside of a licensed pharmacy shall be reimbursed at or below the Average Wholesale Price (AWP) plus a dispensing fee of $4.18. AWP or its equivalent as registered by the National Drug Code shall be set forth as published for that drug on that date in Medi-span. Prescriptions filled at a licensed pharmacy will continue to be paid at U&C.

Effective 11/20/12, the maximum reimbursement for repackaged drugs shall be the Average Wholesale Price for the underlying drug product, as identified by its National Drug Code from the original labeler.

Note: There are some general HCPCS codes on the fee schedule (e.g., J3490: unclassified drug) that show a fee or POC76/POC53.2 (i.e., pay 76% or 53.2% of charge). Some people claim these J codes should be used for prescription bills, and payment should be at that fee or at POC. This is not correct. People should not use HCPCS codes to game the system.

How are implants/carve-outs paid?

From treatment from 9/1/11 and thereafter, implants are paid at 25% above the net manufacturer's invoice price less rebates, plus actual reasonable and customary shipping charges.

This new provision applies regardless of whether the implant charge was submitted by a provider, distributor, manufacturer, etc. It also applies whether billed on a separate or combined bill.

Example:

Implant invoice = $1,010 + $10 tax = $1,020
Rebate = $20
Reimbursement = $1,020 - $20 = $1,000 * 1.25 = $1,250
Shipping = $25
Reimbursement = $1,250 + $25 = $1,275
The other carve-out categories (non-implantable devices) continue to be paid at 65% of the charged amount.

For treatment from 2/1/06 - 7/5/10 and from 10/29/10 - 9/10/11, implants are paid at 65% of the charged amount "at the provider's normal rates under its standard chargemaster." In the absence of a chargemaster, it is reasonable for the payer to determine normal rates in an area.

From 7/6/10 - 10/28/10, implants are paid at 25% above the net manufacturer's invoice price less rebates, plus actual reasonable and customary shipping charges.

Statute: Section 8.2(a-1)(5); Rule 7110.90(g)(2), 7110.90(h)(7)(F)(iv)

How is durable medical equipment (DME) paid?

Equipment--and any code that begins with a letter--is in the Healthcare Common Procedure Coding System (HCPCS) fee schedule. Go to the Non-Hospital Fee Schedule section on the fee schedule website, and click the 4th box down.

When an ambulance travels from one geozip to another, which one should count for billing?

The most common and universally accepted practice is to use the geozip of the place where the patient was picked up.

How should bills from an urgent care center be paid?

Hospitals that run an urgent care center and bill with the hospital tax ID# should follow the Hospital Outpatient fee schedule. Other nonhospital urgent care centers should be reimbursed per the Professional Services fee schedule.

How are inpatient rehabilitation services paid?

Ordinary inpatient rehabilitation services are paid according to the Hospital Inpatient fee schedule. There is a special fee schedule for three specially-designated rehabilitation hospitals: Marianjoy, Schwab Rehab Center, and the Rehabilitation Institute of Chicago. These hospitals specialize in brain injury, spinal cord injury, etc.

How can I find out which hospitals are designated as Level I & II trauma centers?

The Level I & II trauma centers list.

How can I find another State's Workers' Compensation Fee Schedule?

The Workers' Compensation Research Institute's list of links to the 50 states' fee schedules.

How are the fees adjusted each year?

According to Section 8.2(a) of the Act, on January 1 of each year the IWCC adjusts all the fees by the percentage change in the Consumer Price Index-All Urban Consumers, All Items (1982-84=100) for the 12-month period ending August 31 of the previous year. Over the life of the fee schedule, in 2015 fees will run 38% below medical inflation.

Annual Adjustments

*Effective 9/1/11, pursuant to HB1698, all fees were reduced by 30%.

What services are not subject to the fee schedule?

The fee schedule covers only those areas of medical treatment specifically listed on the IWCC website. If a service is not covered under the fee schedule, it should be paid at the usual and customary rate.

The fee schedule does not apply, for example, to skilled nursing facilities or Section 12 medical exams (also known as independent medical exams). To the extent that there are fees listed for home health services, outpatient renal dialysis, or psychiatric hospitals (freestanding or dedicated psychiatric units in acute care hospitals) in the HCPCS and CPT professional services fee schedules, these fees should be applied.

Because the historical charge data associated with Miscellaneous Services codes (99024-99091) were extremely variable, the Commission removed these CPT codes from the schedule, effective 2/1/09. They should be paid at the usual and customary rate.

In addition, because the fee schedule only covers treatment, it does not set maximum payment for procedures performed for litigation, e.g., an evaluative exam conducted at the employer's request (aka Section 12 exam). Payment for such procedures are determined between the provider and payer.

By law, when the Commission is unable to calculate a fee for a procedure, there is a default payment provision. For treatment between 2/1/06 - 8/31/11, the default is POC76, meaning payment shall be 76% of the charged amount. Effective 9/1/11, the default is 53.2% of the charged amount (POC53.2).

If a procedure isn't covered under the fee schedule, payment should be at the usual and customary rate. The law and rules make no mention of what the usual and customary rate is. No formula was adopted. If there is a dispute, the parties would take the issue before an arbitrator.

Why were some Hospital Outpatient and ASTC codes omitted from the 2014 fee schedules?

Medicare changed a number of primary and stand-alone procedures, and excluded some from its template. Because we use the Medicare template to create the hospital outpatient and ASTC fee schedules, these codes were not included in the 2014 fee schedules.

The Workers' Compensation Medical Fee Advisory Board has discussed this issue but has not reached a consensus. By law, Illinois fee schedule amounts are determined using historical charge data. To assign new fee schedule amounts in response to the Medicare changes, we would have to promulgate rules, which is a months-long process.

See the FAQ on how to pay procedures not on the outpatient surgical and ASTC fee schedule. In addition, parties may contract for reimbursement amounts, as allowed in Section 8.2(f).

How should we pay procedures that are not listed in Hospital Outpatient Surgical and ASTC schedules?

The IWCC used the CMS list of Hospital Outpatient Surgical Facility (HOSF) procedure codes (not reimbursement levels) to develop the HOSF and ASTC fee schedules. This list is more extensive than that approved by CMS for ASTCs. CMS excludes codes from this list for two main reasons:

1. The procedure is relatively minor and the facility component is included in the physician’s charge for the procedure;
2. The procedure is commonly done as inpatient.
   

For procedures that CMS classifies as inpatient, the IWCC recommends that payers and providers should use the POC76 (before 9/1/11)/POC53.2 (on or after 9/1/11) default for these facility bills. Codes excluded from the template as being bundled into the procedure would continue at a “no reimbursement level.”

Does the fee schedule cover medical reports or copying fees?

A provider may not charge a fee for writing a standard report that is generated in the normal course of treatment (e.g., office visit documentation). If the provider writes a special report that is unusual or outside the standard reporting forms, then an additional fee may be charged.

The fee schedule does not set a fee for the usual code that identifies a special medical report, CPT 99080, nor does it show the default of POC76/53.2. Whenever the fee schedule does not cover a procedure, the usual and customary rate would apply.

The fee schedule does not cover fees for copying medical reports. The usual and customary rate would apply.

If medical records are subpoenaed, there is no per-page copying fee allowed. The law and rules provide only for mileage and a mandatory $20 fee. (See Section 16 of act; Section 7030.50 of rules; Circuit Courts Act)

What can the provider do if the payer won’t pay correctly?

You have at least six options:

1. The medical provider can charge interest on unpaid amounts. Effective 6/28/11, payments are due within 30 days of the date the payer receives substantially all the information needed to adjudicate a bill. Unpaid bills accrue interest of 1% per month, under Section 8.2(d) of the Act. Proceed as you would with any other unpaid bill by submitting a statement for accrued interest as part of the overall bill. From 2/1/06 - 6/28/11, payments were due 60 days from the date of receipt. In a 2012 bulletin, the Department of Insurance notified insurers and TPAs it would enforce this law.
2. The worker can request a hearing regarding unpaid medical bills, and file a petition for penalties and/or attorneys' fees for delay or nonpayment of medical bills. An employer may have to pay the worker's attorney fees under Section 16; Section 19(k) penalties can run up to 50% of the amount due; Section 19(l) penalties can run up to $30 per day, with a maximum of $10,000. These penalties and fees are payable to the worker.
3. If the dispute involves issues relating to terms and conditions outlined within a contract, including negotiated discounts between a health care provider and a payer, the Illinois Department of Insurance may be able to help. Contact the Managed Care Unit at the Department of Insurance.
4. If a person misrepresents the facts for the purpose of denying or obtaining payment, he or she may be guilty of workers' compensation fraud. Section 25.5 provides that fraud is a Class 4 felony. Any person or organization found to have violated this provision is subject to criminal penalties and can be ordered to pay restitution and fines. If you think fraud may be involved, contact the WC Fraud unit at the Illinois Department of Insurance (toll-free 877/923-8648).
5. If you believe an insurer is behaving inappropriately, you may email the Department of Insurance Consumer Affairs Division. IDOI cannot investigate the merits of the workers' compensation case, nor will it investigate a "he said/she said" argument. You must provide evidence of inappropriate behavior, e.g., show a company paid last year's fee schedule amounts well into the new year. If you have a problem with a Third Party Administrator, make sure you identify the insurer that hired the TPA.
6. Consult your own legal counsel about possible courses of action against the employee or employer.
7. Please see the Illinois Department of Insurance website for how to file a complaint: https://idoi.illinois.gov/consumers/file-a-complaint.html
   

Note that Section 10(a) of the Health Care Services Lien Act prohibits health care professionals and providers from placing a lien on an injured worker's award or settlement.

Should we pay medical bills according to our contract or the fee schedule?

If parties enter into a contract for medical services covered under the Workers' Compensation Act, it prevails over the fee schedule. The Workers' Compensation Medical Fee Advisory Board drafted a statement to clarify the the precedence of an existing contract over the fee schedule.

If there is not a contract, Sections 8(a) and 8.2 require that the employer shall pay the lesser of the provider's actual charges or the amount set by the fee schedule.

Source: Section 8.2(f)) of the IL WC Act and Section 7110.90(d) of the Administrative Rules

Where can we find someone to review a bill for us and determine the correct payment under the fee schedule?

The IWCC can provide general guidance, as listed on this web page, but the staff cannot address individual cases.

Because medical bills can be complex, parties may wish to hire a company to calculate the fee schedule amount for them. The Commission cannot recommend bill review companies, but we offer a list of bill review companies as a convenience.

If other bill review companies would like to get on the list, email us your company name, location, and contact information.

Is balance billing allowed?

The term "balance billing" refers to an attempt by a medical provider to get an injured worker to pay the unpaid balance of a medical bill, or for services that were found to be excessive or unnecessary.

Section 8.2(e) of the Act provides a provider may seek payment of the actual charges from the employee if the employer notifies a provider that it does not consider the illness or injury to be compensable. If an employer notifies a provider that it will pay only a portion of a bill, the provider may seek payment of the unpaid portion from the employee up to the lesser of the actual charge, the negotiated rate, or the rate in the fee schedule.

If an employee informs the provider that a claim is on file at the Commission, the provider must cease all efforts to collect payment from the employee. Any statute of limitations or statute of repose applicable to the provider's efforts to collect from the employee is tolled from the date that the employee files the application with the Commission until the date that the provider is permitted to resume collection.

While the claim at the Commission is pending, the provider may mail the employee reminders that the employee will be responsible for payment of the bill when the provider is able to resume collection efforts. The provider may request information about the Commission claim and if the employee fails to respond or provide the information within 90 days, the provider is entitled to resume collection efforts and the employee is responsible for payment of the bills. The reminders shall not be provided to any credit agency. Check on the status of a case.

Upon final award or settlement, a provider may resume efforts to collect payment from the employee and the employee shall be responsible for payment of any outstanding bills plus interest awarded. If the service is found compensable, the provider shall not require a payment rate, excluding interest, greater than the lesser of the actual charge or payment level set by the Commission in the fee schedule. The employee is responsible for payment for services found not covered or compensable unless agreed otherwise by the provider and employee. Services not covered or not compensable are not subject to the fee schedule.

The law does not give the Commission authority to enforce this provision or to resolve balance billing disputes between injured workers and medical providers. If there is an alleged violation of the balance billing provision, the parties would have to respond the way other allegedly inappropriate bills are handled, and, if unable to resolve the matter, take the issue to circuit court.

To help facilitate such disputes, we have put this information onto the Commission letterhead to download.

Will the IWCC convert to ICD-10 codes?

The US Department of Health and Human Services extended the deadline to October 1, 2015. Previously, it required all HIPAA-covered entities to code all treatment and discharges on or after October 1, 2014 with ICD-10 diagnosis codes.

The only part of the Illinois workers' comp fee schedule that explicitly uses ICD codes is the Inpatient Rehabilitation Hospital fee schedule, which sets a maximum per diem rate. The IWCC will post an updated Rehab Hospital fee schedule in September 2015.

In all other parts of the Illinois fee schedule, the same CPT, HCPCS, and MS-DRG codes will work as before in determining the maximum reimbursement. No regulatory changes are planned.

Where can I find information about modifiers?

Go to Section 8(F) of the Instructions and Guidelines, and the Payment Guide to Global Days.

The multiple procedure modifier applies to surgical procedures only. The multiple procedure modifier does apply on POC procedures.

What do the modifiers NU, RR, and UE mean?

Fees for durable medical equipment vary, depending on whether the equipment is new, old, or rented. According to the HCPCS manual, NU = new equipment; RR = rental; and UE = used equipment.

How should Allied Health Care Professionals be paid for assisting at surgery?

Allied health care professionals use the modifier -AS to designate their assistance in a surgery. Since they do not use the -80, -81, or -82 modifiers listed in the Instructions and Guidelines for assistance at surgery, disputes have arisen over how these professionals should be paid.

Section 9 of the Instructions and Guidelines states:

“Allied health care professionals such as certified registered nurse anesthetists (CRNAs), physician assistants (PAs) and nurse practitioners (NPs) will be reimbursed at the same rate as all other health care professionals when performing, coding and billing for the same services.”

If an allied health care professional provides the same service that a physician would at surgery, then he or she is entitled to the same reimbursement as a physician. The fact that the professional is not a doctor is not a basis to reduce payment. Any automatic coding adjustment that changes an -80 to an -81 based solely on the fact that the surgical assistant is an allied health care professional is inappropriate.

We do understand that there might be a conflicting provision in the NCCI edits, but it is superseded by a specific rule (above) adopted by the Commission.

Conclusion: Allied health care providers should be paid as follows:

For 80: The lesser of 20% of the fee schedule amount or 20% of the primary surgeon's fee.

For 81: The lesser of 15% of the fee schedule amount or 15% of the primary surgeon's fee.

For 82: The lesser of 20% of the fee schedule amount or 20% of the primary surgeon's fee.

How are healthcare professionals paid in hospital settings?

All healthcare professionals who perform services in a hospital setting and bill for these services using their own tax ID number on a separate claim form are subject to the Professional Services and/or HCPCS fee schedule. While these services are provided in a hospital setting and not a physician’s office, the application of the fee schedule will be the same as though these services had been provided in the physician’s office. In other words, there is no site-of-service adjustment.

If professional services (e.g., a radiologist reading an x-ray, or CRNA services) are billed by the hospital using its tax ID number for these services, then the professional services fee schedule will not apply; rather, payment will be POC76/POC53.2.

Physical therapy is unique. If physical medicine services are provided in a hospital setting and billed under the hospital's tax ID number, they would be subject to the Hospital Outpatient fee schedule.

What does "POC" mean?

"POC" means percentage of charge. By law, whenever the Commission is unable to calculate a fee for a procedure, payment defaults to POC. If the fee schedule says "POC76," payment should be 76% of the provider's charge. If the fee schedule says "POC53.2," payment should be 53.2% of the provider's charge. Effective 9/1/11, when the legislature reduced the fee schedule, across the board, by 30%, POC76 was reduced to POC53.2.

The multiple procedure modifier does apply on POC procedures.

What is happening with electronic claims?

Section 8.2a of the Act requires the Department of Insurance (DOI) to file rules that will require employers and insurers to accept electronic medical claims by June 30, 2012, but the rules have not been finalized.

DOI filed proposed rules on November 15, 2012 but withdrew them on November 22, 2013. DOI proposed rules appear in the August 8, 2014 version (Issue 32) of the Illinois Register.

Must bills be submitted on certain forms?

Commission rules state that hospital inpatient services, implants, and professional services charged as part of hospital outpatient services should be billed on the UB-04, CMS1450, or CMS1500 claim form. In other cases, UB-04 and CMS1500 forms are commonly used. In the interest of facilitating transactions and minimizing disputes, we encourage providers to use the standard forms

How are outliers paid?

Before 9/1/11, an outlier is defined as a hospital inpatient or hospital outpatient surgical bill that involves extraordinary treatment in which the bill is at least twice the fee schedule amount for the assigned procedure after subtracting carve-out revenue codes. Payment for an outlier shall be the sum of 1) the assigned fee schedule amount, plus 2) 76% of the charges that exceed the fee schedule amount, plus 3) 65% of charge for the carve-out revenue codes.

Effective 9/1/11, an outlier is defined as a hospital inpatient or hospital outpatient surgical bill that involves extraordinary treatment in which the bill is at least 2.857 times the fee schedule amount for the assigned procedure after subtracting carve-out revenue codes. Payment for an outlier shall be the sum of: 1) the assigned fee schedule amount, plus 2) 53.2% of the charges that exceed the fee schedule amount, plus 3) 125% of the net manufacturer's invoice price less rebates, plus actual reasonable and customary shipping charges for implants, plus 4) 65% of charge for the non-implantable carve-out revenue codes. (Rule 7110.90(h)(6)(G)(ii), 7110.90(h)(7)(F)(iv))

It is the Commission's position that the 53.2% reduction in HB 1698 supercedes any administrative rules that are inconsistent with this reduction, including the outlier rule. Thus, it would be the Commission's contention that the reduction to the outlier was effective when the 30% reduction was imposed by HB 1698. Any rule that is in contradiction to a statute does not have the force and effect of law.

What information should be provided with a medical bill and/or Explanation of Benefits?

Section 8.2(d) requires payers to pay bills that contain "substantially all the required data elements necessary to adjudicate the bill." Parties may disagree over what constitutes a complete bill.

We encourage payers to provide specific information about why a bill was rejected or reduced. Cite the particular document and page as the basis for the action taken, if possible. It is not appropriate to tell providers to call the IWCC to find out why a payer paid a bill as it did. Please report such behavior to the Illinois Department of Insurance.

The Workers' Compensation Medical Fee Advisory Board has discussed the issue but did not reach a conclusion. The only way to get a binding decision at this point is for the parties to take the issue before an arbitrator. Once a case is resolved and precedent set, we'll all know more about what is required.

In the meantime, in the absence of regulations, we encourage people to cooperate and to follow common conventions.

Is there a statute of limitations for submitting a medical bill?

The Illinois Workers' Compensation Act does not provide a statute of limitations for submitting or paying medical bills. Because we cannot offer legal advice, parties may wish to 1) seek a legal opinion on contract law and general statute of limitations found in Illinois law; 2) follow common billing and reimbursement conventions.

We encourage everyone to do what they can to expedite matters and avoid problems. Delays could result in charges not being awarded and bills becoming uncollectable under the balance billing provision.

How do I pay bills where there are professional and technical components (PC/TC)?

In radiology, pathology and laboratory, and physical medicine, a doctor may bill for the professional component (modifier PC or 26) and a facility may bill for the technical component (modifier TC). A technician may take a x-ray, for example, and a radiologist would read it.

Most of the time, each component is billed separately. When possible, we calculated a fee for each component. If a dollar amount appears under the appropriate PC/TC column, that represents the maximum payment for that component.

If we didn't have enough data to calculate a fee, by law the schedule defaults to POC76/POC53.2, which means to pay either component 76% or 53.2% (as of 9/1/11) of the charged amount. If a component is billed separately, it should be paid at 76% or 53.2% of the charged amount. The PC/TC columns, which show that the bill should be split (e.g., 20/80), are relevant only if both components are billed at the same time.

Note: A TC modifier is not required on hospital UB-04 bills. It is understood that a hospital is billing for the technical component.

How is a bill with pass-through charges handled?

First subtract the pass-through charges (also known as revenue code charges) from the bill, then apply the fee schedule.

If, for example, a bill comes in for $50,000 with $10,000 in pass-through charges, apply the remaining $40,000 to the fee schedule amount, and pay the lesser of the $40,000 or the fee schedule amount. Then pay the pass-through charges under the appropriate provision.

You should clearly identify the different charges, but separate bills are not necessary.

Do the fees represent time units?

If the description of a code includes a time increment, then the fee schedule incorporates that time increment. If the description does not contain a time increment, then the fee schedule amount reflects reimbursement for an episode as is generally accepted in Illinois.

How should S and T codes be paid?

If there is a listed value for an S code, use that value. If it is listed as POC76/POC53.2, or there is no listing, pay that percentage of charge. All T codes should be paid at POC76/POC53.2.

How should the payer handle a bill with incorrect codes?

The Instructions and Guidelines direct users to reference materials incorporated into the fee schedule (e.g., Correct Coding Initiative, AMA’s CPT). To the extent that a medical bill is submitted in a manner inconsistent with these documents, then a bill can be questioned. The payer could contact the provider and try to resolve such issues. If the parties cannot resolve the issue, the employer or worker may file a petition for a hearing before an arbitrator regarding unpaid medical bills.

Does the attorney have to itemize each medical provider's bill to fit within the fee schedule? For example, instead of listing the charge for an office visit, should he or she list the fee schedule amount?

If bills are not paid and the case goes to arbitration, attorneys should submit the bills as they are, and then, in the proposed decision, identify the amount to be awarded. If the bill is less than the fee schedule amount, the bill is awarded at 100% of the charge. If the bill is more than the fee schedule amount, it is awarded at the fee schedule amount.

How does the Commission use the AMA impairment rating?

The AMA Guides are one of five factors the Commission considers when awarding permanent partial disability (PPD) awards for cases with injuries on or after 9/1/11:

1. AMA impairment rating (using the most current edition of the Guides)
2. Occupation
3. Age
4. Future earning capacity
5. Evidence of disability in the treating providers' medical records

The Commission issued guidance to arbitrators regarding the use of American Medical Association impairment ratings:

1. An impairment report is not required to be submitted by the parties with a settlement contract.
2. If an impairment rating is not entered into evidence, the Arbitrator is not precluded from entering a finding of disability.

The preceding two statements are simply provided as guidance of the Commission’s review of the new law and some current relevant arguments and interpretations and are not a rule of general applicability. Each Commissioner and Arbitrator should issue a decision that responds to the factual situation on review before them.

How does the utilization review (UR) law affect the process?

Section 8.7 of the Illinois Workers' Compensation Act provides that an employer may conduct prospective, concurrent, and retrospective review of treatment, as long as the employer complies with the following requirements:

1. Use only approved UR providers that are registered with the Illinois Department of Insurance. UR providers may contact The Managed Care Unit The IDOI UR web page.
2. Evaluate cases using nationally recognized treatment guidelines and evidence-based medicine.
3. Certify compliance with URAC standards for Workers' Compensation Utilization Management (WCUM) or Health Utilization Management (HUM). The summary of URAC guidelines and timeframes.

If you believe a UR company is not following the URAC standards (including the standards on the timeliness of responding to requests), you can contact the representative listed on the list of approved UR providers and/or file a complaint with the Illinois Department of Insurance.

If an employer follows URAC standards when refusing to pay for or authorize medical treatment, there shall be a rebuttable presumption that the employer should not be assessed penalties. When making determinations concerning the reasonableness and necessity of medical bills or treatment, the IWCC will consider UR findings along with all other evidence.

What is a Preferred Provider Program (PPP)?

Sections 8(a) and 8.1a of the Act authorize employers to create Preferred Provider Programs (PPP) for workers' compensation medical care. If the Department of Insurance approves the program, it counts as one of the employee's two choices of medical providers. If the employee does not want to use the PPP, he or she must inform the employer in writing. The employee can then go to one other medical provider and that provider's chain of referrals. The PPP only applies to cases in which the PPP was already approved and in place at the time of the injury.

The Department of Insurance issued rules PPP rules, effective March 4, 2013. The DOI lists PPPs on its website. Click on the links, "Approved Workers' Compensation Preferred Provider Program Administrator Listing" and the "Provisionally Approved Workers' Compensation Preferred Provider Program Administrator Listing." If you have questions on the PPP process, contact the Managed Care Unit the IWCC-approved PPP notification form. If employers wish to notify all employers of the PPP, the Commission and the Medical Fee Advisory Board also offers an advisory form. The forms are also available in Spanish: IWCC-approved PPP notification form in Spanish;advisory form in Spanish

What do I need to know about Workers' Comp Medicare Set-Aside Arrangements?

All parties in a workers' compensation case are responsible under the Medicare secondary payer laws to protect Medicare's interests when resolving wc cases that include future medical expenses.

Medicare recommends parties draft a Workers' Compensation Medicare Set-aside Arrangement (WCMSA), which allocates a portion of the wc settlement for future medical expenses.

The amount of the set-aside is determined on a case-by-case basis and should be reviewed by the Centers for Medicare and Medicaid Services (CMS), in the following situations:

1. The claimant is currently a Medicare beneficiary and the total settlement amount is greater than $25,000; or
2. The claimant has a "reasonable expectation" of Medicare enrollment within 30 months of the settlement date and the anticipated total settlement amount for future medical expenses and disability/lost wages over the life or duration of the settlement agreement is expected to be greater than $250,000.

Once the CMS-determined set-aside amount is exhausted and accurately accounted for to CMS, Medicare will pay as primary payer for future Medicare-covered expenses related to the wc injury.

To address the administrative problems that parties face while awaiting set-aside approval, former Chairman Ruth issued a memo directing cases be continued during the approval period.

For more info, go to the Medicare website.

How does HIPAA affect workers' compensation?

The U.S. Department of Health and Human Services, Office of Civil Rights (OCR), administers the Health Insurance Portability and Accountability Act (HIPAA). It has issued guidelines that indicate that covered providers may disclose health information to workers' compensation insurers, state administrators, employers, and other entities involved in the w.c. system, to the extent disclosure is necessary to comply with, or is required by, state law, or to obtain payment.

The guidelines include a number of frequently asked questions. For more information, please contact the U.S. Department of Health and Human Services.