2005 – 2009 REFORMS IN ILLINOIS WORKERS COMPENSATION
Illinois recently adopted a new “Medical Fee Schedule” effective for all workers compensation medical services rendered on or after Feb. 1, 2006 which now cap the maximum allowable fees for hospital inpatient and doctor charges that Illinois workers compensation will pay for related medical bills. The fee schedule is determined by date of service, zip code where the care is rendered and the medical procedure code. The medical fee schedule is available for free public access on the Illinois Workers Compensation Commission website. (see terms) Illinois Workers Comp Medical Fee Schedule
The Illinois Joint Committee on Administrative Rules (JCAR) approved changes to the Medical Fee Schedule to add maximum payment amounts for Outpatient and Ambulatory Surgery adopted on January 13, 2009. The new Out-patient rates are effective as of February 1, 2009. See Illinois Workers Compensation Medical Fee Schedule Instructions and Guidelines for Treatment ON OR AFTER 2/1/09.
The new Outpatient Medical Fee Schedule sets forth the maximum limits for payment for of 1) ambulatory surgical centers 2) hospital outpatient surgery, radiology, pathology, laboratory, physical medicine and rehabilitation services and 3) new rates for specialized rehabilitation hospitals.
Cost of living increases are built into the fee schedule but the rate of inflation on medical fees is now tied to the Consumer Price Index (CPI-U). Doctors and hospitals are allowed payment of statutory interest at 1% per month on outstanding medical bills. Workers compensation attorneys should know how to apply the new Illinois Medical Fee Schedule for review of any disputed or contested medical bills. Illinois workers comp attorneys should be aware of and apply the new medical fee schedule to disputed bill packages and address the maximum allowable amounts (with interest) in their proposed awards.
Illinois also adopted “Utilization Review” of related medical care as a measure to review the “necessity” or “reasonableness” of proposed or ongoing medical treatment. Medical providers will now be subject to greater scrutiny for the “reasonableness” or “necessity” of medical care based on generally accepted national medical guidelines. Employers and carriers will also be subject to greater scrutiny for any unreasonable “denial of care” decisions that don’t follow the new URAC compliant procedures.
Effective and retroactively applied going back to July 2005, workers’ compensation carriers and adjusters are no longer permitted to deny medical care without documenting a sufficient medical basis. Decisions to deny care are to be determined by a licensed medical professional pursuant to certain URAC standards. This is the essential concept of Utilization Review. Medical determinations are to be made by a licensed medical professional in “peer to peer” type (read equal medical certification) reviews for the necessity of medical care pursuant to “generally accepted medical guidelines”. Failure to follow the statutory requirements in a “denial of care” situation may result in substantial penalties and/ or imposition of attorneys fees.
Contact our Chicago Workers Comp Attorneys at (312) 541-0049 with questions regarding the new Utilization Review provisions.
For assistance or representation: Contact our office at (312) 541-0049 or use the website Contact form
- Summary of July 2005 changes in Illinois Reforms
- New Illinois “Medical Fee Schedule” eff. February 1, 2006
- FAQ’s on URAC accreditation & standards
- New temporary partial disability payments for restricted light duty return to work
- New Illinois adopts Workers Compensation Fraud Provisions (.pdf)
- New Guidelines Illinois Medical Fee Schedule Instructions and Guidelines (before 2/1/09) slow loading .pdf
- New Guidelines Illinois Medical Fee Schedule Instructions and Guidelines (after 2/1/09) slow loading .pdf
- New Rules Illinois Rules on Medical Fee Schedule (before 2/1/09)
- New Rules Illinois Rules on Medical Fee Schedule (after 2/1/09)
For assistance contact a Chicago workers compensation attorney