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  Medical Fee Schedule  

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.

If you have a question that is not addressed on this page, contact us.  Do NOT send confidential documents.  The Commission does not have the resources to review bills or discuss particular cases. 

Services NOT Covered Under the Fee Schedule

Why were some Hospital Outpatient and ASTC codes omitted from the 2014 fee schedules?
Are there any services not subject to the fee schedule?
How should prescription drugs be paid? 
Does the fee schedule apply to medical treatments before February 1, 2006?
Does the fee schedule cover medical reports?   What about copying fees?
Is there a set fee for Section 12 medical exams (also known as independent medical exams)?
Does the fee schedule address missed appointments?


Fee Schedules

What facilities are covered under the Ambulatory Surgical Treatment (AST) fee schedule?
Should unlicensed ASTCs be paid a facility fee?
 
If a procedure is not listed in the AST fee schedule, how should it be paid?

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

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

How should dental services be paid?
How should prescription drugs be paid? 

How are implants paid?
How is durable medical equipment (DME) paid? 
What do the modifiers NU, RR, and UE mean? 
When an ambulance travels from one geozip to another, which one should count for billing?
Are radiology services subject to multiple procedure cutbacks?

How are inpatient rehabilitation services paid?
How can I f
ind 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? 

How are outliers paid?
How should bills from an urgent care center be paid? 
How should Allied Health Care Professionals be paid? 
How are healthcare professionals paid in hospital settings?
What does "POC" mean?

Does the fee schedule apply if the worker/employer/provider is out of state?
How are the fees adjusted each year?

How can I find another state's workers' comp fee schedule? 


Payment Questions

What can I do if the payer won’t pay me correctly? Can I charge interest?
Should we pay medical bills according to our contract or fee schedule?
Where can we find someone to review a bill for us and determine the correct payment under the fee schedule?
What can the medical provider do if a case was settled but the provider was not paid the proper amount? 
Is interest owed if the claim is disputed for valid reasons but later determined to be compensable?


Coding and Billing

Will the IWCC convert to ICD-10 codes?
Why were some Hospital Outpatient and ASTC codes omitted from the 2014 fee schedules?
Is balance billing allowed?
Where can I find information about modifiers?
What is happening with electronic claims?
Must bills be submitted on certain forms? 

What information should be provided with a medical bill and/or Explanation of Benefits? 
How should a payer handle a bill with incorrect codes?
Should a medical provider send bills to the employer or the payer?
Is there a statute of limitations for submitting a medical bill?
How do I pay bills where there are professional and technical components (PC/TC)?

How is a bill with pass-through charges handled?  
Should pass-through charges or outlier charges be billed separately from regular services?
Do the fees represent time units?
How should S and T codes be paid?
 
Can you tell me if I am calculating a bill correctly?
Does the attorney have to itemize each medical provider's bill to fit within the fee schedule?


Other

How does the Commission use the AMA impairment rating?
How does the utilization review (UR) law affect the process? 
What is a Preferred Provider Program (PPP)?
What do I need to know about Workers' Comp Medicare Set-Aside Arrangements?  
How does HIPAA affect workers' compensation?


Fee Schedule Documents  

Fee schedule law as of 8/19/13 (new Preferred Provider Program text)
Fee schedule law as of 6/28/11
Fee schedule law prior to 6/28/11
 
Rules for treatment effective 11/20/12 (new physician-dispensed medicine provision on p. 13)
Rules for treatment effective 11/5/12 implementing 9/1/11 law changes
Rules for treatment between 2/1/09 -7/5/10 and 10/29/10 - 8/31/11
Rules for treatment between 7/6/10 - 10/28/10 
Rules for treatment from 2/1/06 - 1/31/09
 

Instructions and Guidelines for treatment on or after 9/1/11  rev. 2/21/13: On page 7, added 0274-prosthetics/orthotics to list of nonimplantables.  This is a correction, not new policy.

Instructions and Guidelines for treatment between 2/1/09 -7/5/10 and 10/29/10 - 8/31/11
Instructions and Guidelines for treatment between 7/6/10 - 10/28/10
Instructions and Guidelines for treatment from 2/1/06 - 1/31/09 
 
Payment Guide to Global Days  1/1/14--present  pdf version   Excel version
Payment Guide to Global Days  1/1/13--12/31/13  pdf version   Excel version
Payment Guide to Global Days  1/1/12-12/31/12  pdf version   Excel version
Payment Guide to Global Days  2/1/06-12/31/11   pdf version   Excel version
 

National Correct Coding Initiative Coding Policy Manual

Letter stating hot and cold packs are always considered bundled into other physical medicine codes


History of fee schedule developments

House Bill 2137 ordered the Commission to create fee schedules for treatment provided on or after February 1, 2006.  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. 

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.  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.

Click here to 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. 

Click here to read the new guidelines, and the questions and answers from the seminars.   

HB2137 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 before 7/6/10 and from 10/29/10 - 9/10/11 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 changes made by HB1698, including later rule updates as of 11/20/12.

Note that the POC76 default was also decreased by 30% so that default payments are at 53.2% of charge.

From 2006-2012, fees were calculated for each of 29 geozips; effective 1/1/12, there are 14 hospital regions and 4 regions for other nonhospital providers. On the fee schedule web page, click on each region to see a list of counties in that region.

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.

A dental fee schedule took effect for treatment on or after June 20, 2012.  Before then, payment defaulted to the POC amount.

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 shall be 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 fee schedule for Professional Services.  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," meaning they were paid at 53.2% of the change.  Both payers and providers will benefit from unambiguous fee schedule amounts. 


Services NOT Covered Under the Fee Schedule 

 

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).


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).

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.


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. 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 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.

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.


Fee Schedules

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 .

 

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?

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 are implants/carve-outs paid? 

For treatment from 2/1/06 - 7/5/10 and from 10/29/10 - 9/10/11, implants and certain other items* 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 and 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. It is reasonable for the payer to ask for an invoice; if the provider cannot provide an invoice, it shall provide evidence that the charge is billed at the provider's normal rate.

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.

*Revenue codes 0274 (prosthetics/orthotics); 0275 (pacemaker); 0276 (lens implant); 0278 (implants); 0540 and 0545 (ambulance); 0624 (investigational devices); and 0636 (drugs requiring detailed coding).

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.

 

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.

 

Are radiology services subject to multiple procedure cutbacks?

No. Commission rules and the "Payment Guide" refer only to surgical services being subject to the multiple procedure modifier.

 

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?

Click here for the list.

 

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.

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 nonimplantable 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.

 

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.

 

What does "POC" mean?

"POC" means percentage of charge.  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. 

By law, whenever the Commission is unable to calculate a fee for a procedure, payment defaults to POC.  Effective 9/1/11, when the legislature reduced the fee schedule, across the board, by 30%, POC76 was reduced to POC53.2.




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.

Before 6/28/11, 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 did not have a fee schedule at that time, payment is 76% of charge. (Section 7110.90(g) of the rules)

Effective 6/28/11, out-of-state treatment shall 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. (Section 8.2 of the Illinois WC Act)

Effective 11/5/12, if the employee lives out of state, reimbursement shall be the lesser of the actual charge or the fee schedule amount for the hearing site, i.e., the location established by the Commission for hearings. All Cook County cases, for example, are set in Chicago. The hearing site is designated as the setting on the case information screen. (Section 7110.90(g)(1)(B) of the rules)

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. Over the life of the fee schedule, in 2014 fees will run 38% below medical inflation.

Annual Adjustments
Effective date
CPI-Medical
CPI-U/IL FS
Annual Difference

February 1, 2006

4.37%

4.90%

0.53%

January 1, 2007

4.26%

3.80%

-0.46%

January 1, 2008

4.52%

1.97%

-2.55%

January 1, 2009

3.26%

5.37%

2.11%

January 1, 2010

3.31%

-1.48%

-4.79%

January 1, 2011

1.03%

1.01%

-0.02%

September 1, 2011*

-30.00%*

-30.00%

January 1, 2012

3.19%

3.77%

0.58%

January 1, 2013

4.05%

1.69%

-2.36%

January 1, 2014

2.34%

1.52%

-0.82%

Cumulative

30.33%

-7.45%

-37.78%

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

 

How can I find another state's workers' compensation fee schedule?

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

 


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 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 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.

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 parties enter into a contract for medical services, it 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.

 

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.

 


Coding and Billing

 

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.

 

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 Hospital Outpatient 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 may have to promulgate rules, which is a months-long process.

In the meantime, parties may contract for reimbursement amounts, as allowed in Section 8.2(f).


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. 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 I find information about modifiers?

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


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 reported that the International Association of Industrial Accident Boards and Commissions (IAIABC) has adopted a newer version of its model rule, on which the DOI based its proposed rule.  DOI reported it will file another proposed rules that will follow the IAIABC Model Rule, Version 2.1.  DOI will also consider the public comments it received during the earlier rule process. 

 

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 

 

How does the Commission use the AMA impairment rating?

Pursuant to HB1698, 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.  The five factors are:

1.
AMA impairment rating (always use 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 has issued the following guidance to arbitrators regarding the use of American Medical Association impairment ratings:

"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:

1. Use only approved UR providers that are registered with the Illinois Department of Insurance.  UR providers may contact Johnel Butler (217/558-4542) at the IDOI to register. Click here for 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). For a summary of URAC guidelines and timeframes, click here.

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 the page, http://insurance.illinois.gov/Consumer/consumer.asp/. 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 Kari Dennison (217/782-1771) at the Department of Insurance.

After an employee notifies the employer of an injury, an employer that has a PPP must notify the employee of this in writing using 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.

 

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