Disclaimer: The information on this page is intended
to help individuals understand the medical fee schedule, but
it cannot be construed as legal advice. As with any public policy,
there are a number of issues that the law and rules do not address,
and law is always subject to interpretation. Future Commission
and/or court opinions may provide guidance on such issues. The
Commission cannot offer individuals legal advice or offer advisory
opinions. If you need a legal opinion, we suggest you consult
your own legal counsel.
Instructions
and Guidelines for treatment on or after 9/1/11 will be approved during the rule-making process. This may take several months. The changes in the law have taken effect.
Surgical
procedures are assigned a base value, e.g., 3 units for
a closed procedure on a wrist, 4 units for a closed procedure
on a shoulder. From 2/1/06-12/31/11, the fee schedules used the base values listed for each procedure in the "2006 Relative Value Guide." As of 1/1/12, users should refer to the most recent version of manuals.
The
guide is published by the American Society of Anesthesiologists
(847/825-5586; cost $25).
Conversion
factor
A
conversion factor is a dollar amount used to determine the
amount of reimbursement for most anesthesia services. The
conversion factor is multiplied by time units, base value
units, modifier units, and qualifying circumstances units.
Calculating the correct fee schedule amount can be determined
by consulting the Instructions and Guidelines, ASA Relative
Value Guide, and the AMA CPT.
Geozip/Region
The maximum payment is set by the location where the medical treatment is provided.
By law, from 2/1/06 - 12/31/11, fee schedule amounts were set for each three-digit zip code in Illinois, called a
geozip.
Effective 1/1/12, the geozips were replaced by regions as specified in Section 8.2(a-1) of the Act. Click here to view the law that defines the regions by county (page 6 in linked document). On the fee schedule page, click on each region to view a list of the counties in that region.
Because zip codes can spread through several counties, users must change their systems. Identify the county that the city is in. It is the parties' responsibility to identify the correct region. To view an interactive map that identifies counties in Illinois, click here. Make sure you click the box, "show counties."
Modifier
The IWCC adopted the AMA CPT modifiers, two-digit numeric or alpha attachments that indicate that a service was altered in some way from
the CPT description without actually changing
the basic CPT definition.
They are listed in Section 8E of the Instructions and Guidelines.
Modifiers
can indicate, among other things, that
a) the procedure was either professional or technical;
b) the procedure was complicated or unusual;
c) the procedure was bilateral;
d) an adjunctive service was performed;
e) that multiple procedures were performed; or
f) a procedure was performed by more than one person.
POC76 - POC53.2
POC = Percent Of Charge
When the Commission is unable to calculate a fee for
a procedure, there is a default payment provision.
From 2/1/06 - 8/31/11, the default is POC76, meaning payment shall be 76% of the charged amount.
Effective 9/1/11, all default payments are 53.2% of the charged amount (POC53.2).
History of fee schedule developments
The
IWCC first implemented fee
schedules for treatment provided on or after February
1, 2006. Each January 1, the fees are adjusted by the Consumer
Price Index. Each year, the vendor, Ingenix/Optimum, 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. As a result,
some fees were set, by default, at 76% of the charged amount.
Effective February
1, 2009, the Commission created new fee schedules for the following areas: 1) ambulatory
surgical treatment centers; 2) hospital outpatient radiology, pathology and laboratory, physical
medicine and rehabilitation services, and surgical services; and 3) rehabilitation hospitals.On
6/30/09, the Commission converted the hospital inpatient
fee schedule to the new MS-DRG coding system.
In
November and December 2009, the Commission held seven seminars
around the state and one statewide webinar to explain the fee
schedule to payers and medical providers. 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.
The legislature directed the Commission to report
on the fee schedule's implementation by January 1, 2010. The Commission worked
with the Workers' Compensation Medical Fee Advisory Board 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. To
read the report to the General Assembly, click here.
Following
up on the issues in the General Assembly report, the
WCMFAB and the Commission agreed to change the reimbursement method
for implants and to add accredited-but-not-licensed ambulatory
surgical facilities to the ASTC fee schedule. On
July 6, 2010, the Commission filed emergency rules on these two
issues, but they were later repealed on October 28, 2010. All treatment
between 7/6/10 and 10/28/10 shall be paid according to the emergency
rules. Treatment outside of those dates shall be paid at the 65%-of-charge
rule.
On June
28, 2011, Governor Quinn signed House
Bill 1698 (Public Act 97-18). Click here to read
a summary of the fee schedule changes. Click here to view the new, 30% lower, fees that took effect 9/1/11. Note that the POC76 default was also decreased by 30% so that default payments are at 53.2% of charge.
Services
NOT Covered Under the Fee Schedule
Are
there any services not subject to the fee schedule?
Yes. 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. 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).
How should pharmacy drugs be paid?
Before 6/28/11, prescriptions should be paid at the usual and
customary (U&C) 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.
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 Medispan. Prescriptions filled at a licensed pharmacy will continue to be paid at U&C.
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.
Does
the fee schedule apply to medical treatments before February
1, 2006?
No.
The schedule only covers treatments that are covered under the
Act and are provided on or after 2/1/06. The date of injury
is not relevant. Before 2/1/06, payment was at the usual
and customary rate. U&C is not defined in our regulations.
Does
the fee schedule cover medical reports? What about 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)
Is
there a set fee for Section 12 medical exams (also known as independent
medical exams)?
No.
An evaluative exam conducted at the employer's request is not
considered treatment and is not covered under the fee schedule.
Does
the fee schedule address missed appointments?
No. The fee schedule only applies to services actually rendered
in the treatment of an injured worker.
Questions
Related to Particular Fee Schedule Categories
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 (aka The Joint Commission) is not online.
Should
unlicensed ASTCs be paid a facility fee?
Emergency rules that were in effect between 7/6/10 - 10/28/10 provided that accredited surgical treatment facilities shall be paid under the Ambulatory Surgical Treatment Center (ASTC) fee schedule. Treatment during that time should follow that rule.
The emergency rule was repealed, however, and before and after the dates the emergency rule was in effect, payment methods varied. Some payers paid the accredited facilities, some paid U&C, some paid POC76, etc.
The legislature then responded by enacting a law. Effective 9/1/11, accredited ambulatory surgical treatment facilities are included in the ASTC fee schedule. A provider must be licensed or accredited as a facility to be eligible for a facility fee.
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?
The Commission has not yet created a fee schedule for dental services. We are working with the Illinois State Dental Society to create a schedule. Until then, the default provision applies. From 2/1/06 - 8/31/11, the default is POC76, meaning payment shall be 76% of the charged amount. Effective 9/1/11, all default payments are 53.2% of the charged amount (POC53.2). Parties are always free to contract for amounts different from the fee schedule.
How are
implants/carve-outs paid?
From 2/1/06 - 7/6/10, implants and certain other items
were 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.
In response to concerns raised over this rule, the Commission filed an emergency rule on 7/6/10 that provided
that implants shall be paid at 25% above the net manufacturer's
invoice price less rebates, plus actual reasonable and customary
shipping charges. Under
this provision, it is reasonable to demand an invoice.
This rule took effect on July 6th, but it did not
receive final acceptance, and it was repealed on October 28, 2010.
All treatment between 7/6/10 and 10/28/10 shall be paid according
to the 25%-above-invoice emergency rule. Treatment before and
after those dates shall be paid at the 65%-of-charge rule.
Under the new law (Section 8.2(a-1)(5)), effective 9/1/11, implants are paid at 25% above the net manufacturer's invoice price less rebates, plus actual reasonable and customary shipping charges. This 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.
The other carve-out categories--non-implantable devices--continue to be paid at 65% of the charged amount.
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.
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.
Did
the IWCC adopt the new MS-DRGs?
Yes. Medicare changed its inpatient coding from the DRG (Diagnosis
Related Group) to the MS-DRG (Medical Severity-Diagnosis Related
Group) system, and the Commission adapted to the change as of June 30, 2009. To view the new inpatient fee schedule, click on the button in
the "treatment year" category that says, "New MS-DRG
hospital inpatient fee schedule 6/30/09." For prior dates of treatment, the inpatient fee schedule uses
DRGs. Providers and payers should work together to translate these
bills using the CMS crosswalk, CMS Grouper
Version 24.0.
How
can I find out which hospitals are designated as Level I &
II trauma centers?
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.”
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.
House Bill 1698 ordered a 30% cut to all fee schedule amounts. Accordingly, as of 9/1/1, 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 nonimplantable carve-out revenue codes.
Payment
Questions
What
can I do if the payer won’t pay me correctly? Can I charge interest?
You have at least five 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 new Section 8.2(d). Before 6/28/11, payments were due 60 days from the date of receipt. Proceed
as you would with any other unpaid bill by submitting
a statement for accrued interest as part of the overall
bill.
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 Kari Dennison, Managed Care Division, IDOI, at 217/782-1771 or kari.dennison@illinois.gov.
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 contact Iris Canto, Consumer Affairs Division, IDOI,
at 312/814-2420 or iris.canto@illinois.gov, and/or file
a complaint with the Illinois Department of Insurance.
If you choose to file the complaint online, select the link for workers' compensation. If you choose a hard copy of the form, click on the link for property and casualty. Please send us a copy, too, so we know what is happening.
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.
Should we pay medical bills according to our contract
or the fee schedule?
If
there is a contract for medical services, the contract prevails
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.
The
Workers' Compensation Medical Fee Advisory Board has drafted
a statement to
clarify the law (Section 8.2(f)) and rules (Section 7110.90(d))
regarding the precedence of an existing contract over the
fee schedule.
Is
balance billing allowed?
No. 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. Click
here to 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 Commission letterhead. Click
here to download.
Where
can we find someone to review a bill for us and determine
the correct payment under the fee schedule?
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 companies as a convenience. Click
here for the list.
If
other bill review companies would like to get on the list, email us your
company name, location, and contact information.
What
can the medical provider do if a case was settled but the
provider was not paid the proper amount?
By law, only employees and employers are parties to the Commission's
court process. Medical providers cannot petition the Commission
on their own.
The Commission cannot offer legal advice on this matter. We
suggest the provider consult its own legal counsel about possible
courses of action against the employee or employer.
Is
interest owed if the claim is disputed for valid reasons but
later determined to be compensable?
Yes, provided the requirements of Section 8.2(d) are met.
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 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.
How
should Allied Health Care Professionals be paid?
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.
Coding
and Billing
Must
bills be submitted on certain forms?
Section
8.2(d) of the WC Act provides that medical bills shall be
paid within 30 days of the date the payer receives substantially
all the information needed to adjudicate a bill. Failure to
provide the payer with key information about a diagnosis,
procedure code, location of treatment, or other necessary
information might result in undesirable disputes and delays
in processing.
The standard UB-04 and CMS1500 forms contain these necessary
data elements. The IWCC rules do not explicitly require all
these forms to be used all the time. The rules do 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
the interest of facilitating transactions and minimizing disputes,
we do encourage providers to use the above-mentioned forms.
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.
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.
Should
a medical provider send bills to the employer or the payer?
Throughout the Illinois Workers' Compensation Act, there are
many references to the employer where, in practice, the payer
(an insurer or third party administrator) assumes responsibility
for the employer. Section 6(b), for example, says the
employer shall file accident reports, but the payer usually
files them on the employer's behalf. The payer is understood
to stand in the shoes of the employer.
A safe policy, therefore, would
be for a provider to submit the bill to the payer, when known.
Another option would be to submit the bill to both the employer
and the payer.
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.
Should pass-through charges or outlier charges be billed
separately from regular services?
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.
Can
you tell me if I am calculating a bill correctly?
We can provide general answers, as listed on this web page,
but we do not have the resources to address individual calculations.
If
parties cannot reach agreement over a bill, the worker would
request 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.
Other
Does
the Illinois fee schedule apply if the worker/employer/medical
provider is in another state?
The
defining factor is where the worker filed the workers' compensation
claim. If the worker filed the claim in Illinois, then Illinois
law and the Illinois fee schedule apply.
Effective 6/28/11, Section 8.2 of the Illinois WC Act provides that out-of-state treatment
should be paid at the lesser of that state's fee schedule or the Illinois fee schedule amount in the area where the employee resides. If the treating state has no fee schedule, payment shall be the lesser of the actual charge or the Illinois fee schedule amount in the area where the employee resides. The law does not direct how reimbursement shall be handled if the employee lives out of state.
Before 6/28/11, Section 7110.90(g) of the rules provides that out-of-state treatment
shall be paid at the greater of 76% of the charged amount
or that state's fee schedule. If the treating state does not have a fee schedule, payment is 76% of charge.
If
the worker filed a claim in another state, the law in that
state would govern how medical treatment shall be paid. To
determine whether a patient filed a claim in Illinois, contact
the Public
Information Unit (toll-free 866/352-3033).
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. Combined with the 30% cut that took effect 9/1/11, fee schedule amounts are now running 35% below medical inflation over the life of the fee schedule.
Annual
Adjustments
Effective
date
CPI-Medical
CPI-U
IL Fee Schedule
February
1, 2006
4.37%
4.90%
4.90%
January
1, 2007
4.26%
3.80%
3.80%
January
1, 2008
4.52%
1.97%
1.97%
January
1, 2009
3.26%
5.37%
5.37%
January
1, 2010
3.31%
-1.48%
-1.48%
January
1, 2011
1.03%
1.01%
1.01%
September
1, 2011*
-30.00%
January
1, 2012
3.19%
3.77%
3.77%
Total
23.94%
19.34%
-10.66%
*Effective 9/1/11, pursuant to HB1698, all fees were reduced by 30%.
How
does the Commission use the AMA impairment rating?
The Commission has issued guidance to arbitrators regarding the use of American Medical Association impairment ratings in the determination of permanent partial disability awards.
"The Commission has become aware that the new Section 8.1b of the Act, which sets forth the standard for the determination of permanent partial disability, may be subject to a variety of different interpretations. The Commission discussed the new Section 8.1b at its last Commission meeting on November 17, 2011. The Commission was also presented with a memo prepared by Secretary of the Commission, Kimberly Janas, which discussed the possible interpretations of Section 8.1b.
The Commission voted unanimously to provide the following recommendations to the Arbitrators:
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:
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). For a summary
of URAC guidelines and timeframes, click
here.
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.
Section 8.2a of the Act requires the Department of Insurance to propose rules by January 1, 2012 that will require employers and insurers to accept electronic medical claims by June 30, 2012. No information has been posted online yet, though DOI expects to follow the IAIABC model rule. More information will be posted when it is available.
What
do I need to know about Workers' Comp Medicare Set-Aside Arrangements?
All parties in a workers' compensation (wc) 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:
The claimant is currently a Medicare beneficiary and the total
settlement amount is greater than $25,000; or
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.
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.
