Illinois 2025-2026 Regular Session

Illinois House Bill HB2840 Compare Versions

Only one version of the bill is available at this time.

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1	1	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB2840 Introduced , by Rep. Dan Ugaste SYNOPSIS AS INTRODUCED: 820 ILCS 305/8.2 Amends the Workers' Compensation Act. Makes existing medical fee schedules inoperative after August 31, 2026. Provides that the Illinois Workers' Compensation Commission shall establish new medical fee schedules applicable on and after September 1, 2026 in accordance with specified criteria. Provides for 4 non-hospital fee schedules and 14 hospital fee schedules applicable to different geographic areas of the State. Sets forth a procedure for petitioning the Commission if a maximum fee causes a significant limitation on access to quality health care in either a specific field of health care services or a specific geographic limitation on access to health care. Effective immediately. LRB104 11298 SPS 21384 b A BILL FOR 104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB2840 Introduced , by Rep. Dan Ugaste SYNOPSIS AS INTRODUCED: 820 ILCS 305/8.2 820 ILCS 305/8.2 Amends the Workers' Compensation Act. Makes existing medical fee schedules inoperative after August 31, 2026. Provides that the Illinois Workers' Compensation Commission shall establish new medical fee schedules applicable on and after September 1, 2026 in accordance with specified criteria. Provides for 4 non-hospital fee schedules and 14 hospital fee schedules applicable to different geographic areas of the State. Sets forth a procedure for petitioning the Commission if a maximum fee causes a significant limitation on access to quality health care in either a specific field of health care services or a specific geographic limitation on access to health care. Effective immediately. LRB104 11298 SPS 21384 b LRB104 11298 SPS 21384 b A BILL FOR
2	2	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB2840 Introduced , by Rep. Dan Ugaste SYNOPSIS AS INTRODUCED:
3	3	820 ILCS 305/8.2 820 ILCS 305/8.2
4	4	820 ILCS 305/8.2
5	5	Amends the Workers' Compensation Act. Makes existing medical fee schedules inoperative after August 31, 2026. Provides that the Illinois Workers' Compensation Commission shall establish new medical fee schedules applicable on and after September 1, 2026 in accordance with specified criteria. Provides for 4 non-hospital fee schedules and 14 hospital fee schedules applicable to different geographic areas of the State. Sets forth a procedure for petitioning the Commission if a maximum fee causes a significant limitation on access to quality health care in either a specific field of health care services or a specific geographic limitation on access to health care. Effective immediately.
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8	8	A BILL FOR
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11	11	1 AN ACT concerning employment.
12	12	2 Be it enacted by the People of the State of Illinois,
13	13	3 represented in the General Assembly:
14	14	4 Section 5. The Workers' Compensation Act is amended by
15	15	5 changing Section 8.2 as follows:
16	16	6 (820 ILCS 305/8.2)
17	17	7 Sec. 8.2. Fee schedule.
18	18	8 (a) Except as provided for in subsection (c), for
19	19	9 procedures, treatments, or services covered under this Act and
20	20	10 rendered or to be rendered on and after February 1, 2006, the
21	21	11 maximum allowable payment shall be 90% of the 80th percentile
22	22	12 of charges and fees as determined by the Commission utilizing
23	23	13 information provided by employers' and insurers' national
24	24	14 databases, with a minimum of 12,000,000 Illinois line item
25	25	15 charges and fees comprised of health care provider and
26	26	16 hospital charges and fees as of August 1, 2004 but not earlier
27	27	17 than August 1, 2002. These charges and fees are provider
28	28	18 billed amounts and shall not include discounted charges. The
29	29	19 80th percentile is the point on an ordered data set from low to
30	30	20 high such that 80% of the cases are below or equal to that
31	31	21 point and at most 20% are above or equal to that point. The
32	32	22 Commission shall adjust these historical charges and fees as
33	33	23 of August 1, 2004 by the Consumer Price Index-U for the period
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37	37	104TH GENERAL ASSEMBLY State of Illinois 2025 and 2026 HB2840 Introduced , by Rep. Dan Ugaste SYNOPSIS AS INTRODUCED:
38	38	820 ILCS 305/8.2 820 ILCS 305/8.2
39	39	820 ILCS 305/8.2
40	40	Amends the Workers' Compensation Act. Makes existing medical fee schedules inoperative after August 31, 2026. Provides that the Illinois Workers' Compensation Commission shall establish new medical fee schedules applicable on and after September 1, 2026 in accordance with specified criteria. Provides for 4 non-hospital fee schedules and 14 hospital fee schedules applicable to different geographic areas of the State. Sets forth a procedure for petitioning the Commission if a maximum fee causes a significant limitation on access to quality health care in either a specific field of health care services or a specific geographic limitation on access to health care. Effective immediately.
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43	43	A BILL FOR
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49	49	820 ILCS 305/8.2
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68	68	1 August 1, 2004 through September 30, 2005. The Commission
69	69	2 shall establish fee schedules for procedures, treatments, or
70	70	3 services for hospital inpatient, hospital outpatient,
71	71	4 emergency room and trauma, ambulatory surgical treatment
72	72	5 centers, and professional services. These charges and fees
73	73	6 shall be designated by geozip or any smaller geographic unit.
74	74	7 The data shall in no way identify or tend to identify any
75	75	8 patient, employer, or health care provider. As used in this
76	76	9 Section, "geozip" means a three-digit zip code based on data
77	77	10 similarities, geographical similarities, and frequencies. A
78	78	11 geozip does not cross state boundaries. As used in this
79	79	12 Section, "three-digit zip code" means a geographic area in
80	80	13 which all zip codes have the same first 3 digits. If a geozip
81	81	14 does not have the necessary number of charges and fees to
82	82	15 calculate a valid percentile for a specific procedure,
83	83	16 treatment, or service, the Commission may combine data from
84	84	17 the geozip with up to 4 other geozips that are demographically
85	85	18 and economically similar and exhibit similarities in data and
86	86	19 frequencies until the Commission reaches 9 charges or fees for
87	87	20 that specific procedure, treatment, or service. In cases where
88	88	21 the compiled data contains less than 9 charges or fees for a
89	89	22 procedure, treatment, or service, reimbursement shall occur at
90	90	23 76% of charges and fees as determined by the Commission in a
91	91	24 manner consistent with the provisions of this paragraph.
92	92	25 Providers of out-of-state procedures, treatments, services,
93	93	26 products, or supplies shall be reimbursed at the lesser of
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104	104	1 that state's fee schedule amount or the fee schedule amount
105	105	2 for the region in which the employee resides. If no fee
106	106	3 schedule exists in that state, the provider shall be
107	107	4 reimbursed at the lesser of the actual charge or the fee
108	108	5 schedule amount for the region in which the employee resides.
109	109	6 Not later than September 30 in 2006 and each year thereafter,
110	110	7 the Commission shall automatically increase or decrease the
111	111	8 maximum allowable payment for a procedure, treatment, or
112	112	9 service established and in effect on January 1 of that year by
113	113	10 the percentage change in the Consumer Price Index-U for the 12
114	114	11 month period ending August 31 of that year. The increase or
115	115	12 decrease shall become effective on January 1 of the following
116	116	13 year. As used in this Section, "Consumer Price Index-U" means
117	117	14 the index published by the Bureau of Labor Statistics of the
118	118	15 U.S. Department of Labor, that measures the average change in
119	119	16 prices of all goods and services purchased by all urban
120	120	17 consumers, U.S. city average, all items, 1982-84=100.
121	121	18 The provisions of this subsection (a), other than this
122	122	19 sentence, are inoperative after August 31, 2026.
123	123	20 (a-1) Notwithstanding the provisions of subsection (a) and
124	124	21 unless otherwise indicated, the following provisions shall
125	125	22 apply to the medical fee schedule starting on September 1,
126	126	23 2011:
127	127	24 (1) The Commission shall establish and maintain fee
128	128	25 schedules for procedures, treatments, products, services,
129	129	26 or supplies for hospital inpatient, hospital outpatient,
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140	140	1 emergency room, ambulatory surgical treatment centers,
141	141	2 accredited ambulatory surgical treatment facilities,
142	142	3 prescriptions filled and dispensed outside of a licensed
143	143	4 pharmacy, dental services, and professional services. This
144	144	5 fee schedule shall be based on the fee schedule amounts
145	145	6 already established by the Commission pursuant to
146	146	7 subsection (a) of this Section. However, starting on
147	147	8 January 1, 2012, these fee schedule amounts shall be
148	148	9 grouped into geographic regions in the following manner:
149	149	10 (A) Four regions for non-hospital fee schedule
150	150	11 amounts shall be utilized:
151	151	12 (i) Cook County;
152	152	13 (ii) DuPage, Kane, Lake, and Will Counties;
153	153	14 (iii) Bond, Calhoun, Clinton, Jersey,
154	154	15 Macoupin, Madison, Monroe, Montgomery, Randolph,
155	155	16 St. Clair, and Washington Counties; and
156	156	17 (iv) All other counties of the State.
157	157	18 (B) Fourteen regions for hospital fee schedule
158	158	19 amounts shall be utilized:
159	159	20 (i) Cook, DuPage, Will, Kane, McHenry, DeKalb,
160	160	21 Kendall, and Grundy Counties;
161	161	22 (ii) Kankakee County;
162	162	23 (iii) Madison, St. Clair, Macoupin, Clinton,
163	163	24 Monroe, Jersey, Bond, and Calhoun Counties;
164	164	25 (iv) Winnebago and Boone Counties;
165	165	26 (v) Peoria, Tazewell, Woodford, Marshall, and
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176	176	1 Stark Counties;
177	177	2 (vi) Champaign, Piatt, and Ford Counties;
178	178	3 (vii) Rock Island, Henry, and Mercer Counties;
179	179	4 (viii) Sangamon and Menard Counties;
180	180	5 (ix) McLean County;
181	181	6 (x) Lake County;
182	182	7 (xi) Macon County;
183	183	8 (xii) Vermilion County;
184	184	9 (xiii) Alexander County; and
185	185	10 (xiv) All other counties of the State.
186	186	11 (2) If a geozip, as defined in subsection (a) of this
187	187	12 Section, overlaps into one or more of the regions set
188	188	13 forth in this Section, then the Commission shall average
189	189	14 or repeat the charges and fees in a geozip in order to
190	190	15 designate charges and fees for each region.
191	191	16 (3) In cases where the compiled data contains less
192	192	17 than 9 charges or fees for a procedure, treatment,
193	193	18 product, supply, or service or where the fee schedule
194	194	19 amount cannot be determined by the non-discounted charge
195	195	20 data, non-Medicare relative values and conversion factors
196	196	21 derived from established fee schedule amounts, coding
197	197	22 crosswalks, or other data as determined by the Commission,
198	198	23 reimbursement shall occur at 76% of charges and fees until
199	199	24 September 1, 2011 and 53.2% of charges and fees thereafter
200	200	25 as determined by the Commission in a manner consistent
201	201	26 with the provisions of this paragraph.
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212	212	1 (4) To establish additional fee schedule amounts, the
213	213	2 Commission shall utilize provider non-discounted charge
214	214	3 data, non-Medicare relative values and conversion factors
215	215	4 derived from established fee schedule amounts, and coding
216	216	5 crosswalks. The Commission may establish additional fee
217	217	6 schedule amounts based on either the charge or cost of the
218	218	7 procedure, treatment, product, supply, or service.
219	219	8 (5) Implants shall be reimbursed at 25% above the net
220	220	9 manufacturer's invoice price less rebates, plus actual
221	221	10 reasonable and customary shipping charges whether or not
222	222	11 the implant charge is submitted by a provider in
223	223	12 conjunction with a bill for all other services associated
224	224	13 with the implant, submitted by a provider on a separate
225	225	14 claim form, submitted by a distributor, or submitted by
226	226	15 the manufacturer of the implant. "Implants" include the
227	227	16 following codes or any substantially similar updated code
228	228	17 as determined by the Commission: 0274
229	229	18 (prosthetics/orthotics); 0275 (pacemaker); 0276 (lens
230	230	19 implant); 0278 (implants); 0540 and 0545 (ambulance); 0624
231	231	20 (investigational devices); and 0636 (drugs requiring
232	232	21 detailed coding). Non-implantable devices or supplies
233	233	22 within these codes shall be reimbursed at 65% of actual
234	234	23 charge, which is the provider's normal rates under its
235	235	24 standard chargemaster. A standard chargemaster is the
236	236	25 provider's list of charges for procedures, treatments,
237	237	26 products, supplies, or services used to bill payers in a
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248	248	1 consistent manner.
249	249	2 (6) The Commission shall automatically update all
250	250	3 codes and associated rules with the version of the codes
251	251	4 and rules valid on January 1 of that year.
252	252	5 The provisions of this subsection (a-1), other than this
253	253	6 sentence, are inoperative after August 31, 2026.
254	254	7 (a-1.5) The following provisions apply to procedures,
255	255	8 treatments, services, products, and supplies covered under
256	256	9 this Act and rendered or to be rendered on or after September
257	257	10 1, 2026:
258	258	11 (1) In this Section:
259	259	12 "CPT code" means each Current Procedural Terminology
260	260	13 code, for each geographic region specified in subsection
261	261	14 (b) of this Section, included on the most recent medical
262	262	15 fee schedule established by the Commission pursuant to
263	263	16 this Section.
264	264	17 "DRG code" means each current diagnosis related group
265	265	18 code, for each geographic region specified in subsection
266	266	19 (b) of this Section, included on the most recent medical
267	267	20 fee schedule established by the Commission pursuant to
268	268	21 this Section.
269	269	22 "Geozip" means a three-digit zip code based on data
270	270	23 similarities, geographical similarities, and frequencies.
271	271	24 "Health care services" means those CPT and DRG codes
272	272	25 for procedures, treatments, products, services or supplies
273	273	26 for hospital inpatient, hospital outpatient, emergency
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284	284	1 room, ambulatory surgical treatment centers, accredited
285	285	2 ambulatory surgical treatment facilities, and professional
286	286	3 services. "Health care services" does not include codes
287	287	4 classified as healthcare common procedure coding systems
288	288	5 or dental.
289	289	6 "Medicare maximum fee" means, for each CPT and DRG
290	290	7 code, the current maximum fee for that CPT or DRG code
291	291	8 allowed to be charged by the Centers for Medicare and
292	292	9 Medicaid Services for Medicare patients in that geographic
293	293	10 region. The Medicare maximum fee shall be the greater of
294	294	11 (i) the current maximum fee allowed to be charged by the
295	295	12 Centers for Medicare and Medicaid Services for Medicare
296	296	13 patients in the geographic region or (ii) the maximum fee
297	297	14 charged by the Centers for Medicare and Medicaid Services
298	298	15 for Medicare patients in the geographic region on January
299	299	16 1, 2026.
300	300	17 "Medicare percentage amount" means, for each CPT and
301	301	18 DRG code, the workers' compensation maximum fee as a
302	302	19 percentage of the Medicare maximum fee.
303	303	20 "Workers' compensation maximum fee" means, for each
304	304	21 CPT and DRG code, the current maximum fee allowed to be
305	305	22 charged under the medical fee schedule established by the
306	306	23 Commission for that CPT or DRG code in that geographic
307	307	24 region.
308	308	25 (2) The Commission shall establish and maintain fee
309	309	26 schedules for procedures, treatments, products, services,
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320	320	1 or supplies for hospital inpatient, hospital outpatient,
321	321	2 emergency room, ambulatory surgical treatment centers,
322	322	3 accredited ambulatory surgical treatment facilities,
323	323	4 prescriptions filled and dispensed outside of a licensed
324	324	5 pharmacy, dental services, and professional services.
325	325	6 These fee schedule amounts shall be grouped into
326	326	7 geographic regions in the following manner:
327	327	8 (A) Four regions for non-hospital fee schedule
328	328	9 amounts shall be utilized:
329	329	10 (i) Cook County;
330	330	11 (ii) DuPage, Kane, Lake, and Will Counties;
331	331	12 (iii) Bond, Calhoun, Clinton, Jersey,
332	332	13 Macoupin, Madison, Monroe, Montgomery, Randolph,
333	333	14 St. Clair, and Washington Counties; and
334	334	15 (iv) all other counties of the State.
335	335	16 (B) Fourteen regions for hospital fee schedule
336	336	17 amounts shall be utilized:
337	337	18 (i) Cook, DuPage, Will, Kane, McHenry, DeKalb,
338	338	19 Kendall, and Grundy Counties;
339	339	20 (ii) Kankakee County;
340	340	21 (iii) Madison, St. Clair, Macoupin, Clinton,
341	341	22 Monroe, Jersey, Bond, and Calhoun Counties;
342	342	23 (iv) Winnebago and Boone Counties;
343	343	24 (v) Peoria, Tazewell, Woodford, Marshall, and
344	344	25 Stark Counties;
345	345	26 (vi) Champaign, Piatt, and Ford Counties;
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356	356	1 (vii) Rock Island, Henry, and Mercer Counties;
357	357	2 (viii) Sangamon and Menard Counties;
358	358	3 (ix) McLean County;
359	359	4 (x) Lake County;
360	360	5 (xi) Macon County;
361	361	6 (xii) Vermilion County;
362	362	7 (xiii) Alexander County; and
363	363	8 (xiv) all other counties of the State.
364	364	9 If a geozip overlaps into one or more of the regions
365	365	10 set forth in this subsection, then the Commission shall
366	366	11 average or repeat the charges and fees in a geozip in order
367	367	12 to designate charges and fees for each region.
368	368	13 (3) The initial workers' compensation maximum fee for
369	369	14 each CPT and DRG code as of September 1, 2026 shall be
370	370	15 determined as follows:
371	371	16 (A) Within 45 days after the effective date of
372	372	17 this amendatory Act of the 104th General Assembly, the
373	373	18 Commission shall determine the Medicare percentage
374	374	19 amount for each CPT and DRG code using the most recent
375	375	20 data available.
376	376	21 CPT or DRG codes which have a value, but are not
377	377	22 covered expenses under Medicare, are still compensable
378	378	23 under the medical fee schedule according to the rate
379	379	24 described in subparagraph (B).
380	380	25 (B) Within 30 days after the Commission makes the
381	381	26 determinations required under subparagraph (A), the
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392	392	1 Commission shall determine an adjustment to be made to
393	393	2 the workers' compensation maximum fee for each CPT and
394	394	3 DRG code as follows:
395	395	4 (i) if the Medicare percentage amount for that
396	396	5 CPT or DRG code is equal to or less than 125%, then
397	397	6 the workers' compensation maximum fee for that CPT
398	398	7 or DRG code shall be adjusted so that it equals
399	399	8 125% of the most recent Medicare maximum fee for
400	400	9 that CPT or DRG code;
401	401	10 (ii) if the Medicare percentage amount for
402	402	11 that CPT or DRG code is greater than 125% but less
403	403	12 than 150%, then the workers' compensation maximum
404	404	13 fee for that CPT or DRG code shall not be adjusted;
405	405	14 (iii) if the Medicare percentage amount for
406	406	15 that CPT or DRG code is greater than 150% but less
407	407	16 than or equal to 225%, then the workers'
408	408	17 compensation maximum fee for that CPT or DRG code
409	409	18 shall be adjusted so that it equals the greater of
410	410	19 (I) 150% of the most recent Medicare maximum fee
411	411	20 for that CPT or DRG code or (II) 85% of the most
412	412	21 recent workers' compensation maximum amount for
413	413	22 that CPT or DRG code;
414	414	23 (iv) if the Medicare percentage amount for
415	415	24 that CPT or DRG code is greater than 225% but less
416	416	25 than or equal to 428.57%, then the workers'
417	417	26 compensation maximum fee for that CPT or DRG code
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428	428	1 shall be adjusted so that it equals the greater of
429	429	2 (I) 191.25% of the most recent Medicare maximum
430	430	3 fee for that CPT or DRG code or (II) 70% of the
431	431	4 most recent workers' compensation maximum amount
432	432	5 for that CPT or DRG code; or
433	433	6 (v) if the Medicare percentage amount for that
434	434	7 CPT or DRG code is greater than 428.57%, then the
435	435	8 workers' compensation maximum fee for that CPT or
436	436	9 DRG code shall be adjusted so that it equals 300%
437	437	10 of the most recent Medicare maximum fee for that
438	438	11 CPT or DRG code.
439	439	12 The Commission shall promptly publish on its
440	440	13 website the adjustments determined pursuant to this
441	441	14 subparagraph (B).
442	442	15 (C) The initial workers' compensation maximum fee
443	443	16 for each CPT and DRG code as of September 1, 2026 shall
444	444	17 be equal to the workers' compensation maximum fee for
445	445	18 that code as determined and adjusted pursuant to
446	446	19 subparagraph (B), subject to any further adjustments
447	447	20 under paragraph (5) of this subsection.
448	448	21 (4) The Commission, as of September 1, 2027 and
449	449	22 September 1 of each year thereafter, shall adjust the
450	450	23 workers' compensation maximum fee for each CPT or DRG code
451	451	24 to exactly half of the most recent annual increase in the
452	452	25 Consumer Price Index-U.
453	453	26 (5) A person who believes that the workers'
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464	464	1 compensation maximum fee for a CPT or DRG code, as
465	465	2 otherwise determined pursuant to this subsection, creates
466	466	3 or would create upon implementation a significant
467	467	4 limitation on access to quality health care in either a
468	468	5 specific field of health care services or a specific
469	469	6 geographic limitation on access to health care may
470	470	7 petition the Commission to modify the workers'
471	471	8 compensation maximum fee for that CPT or DRG code so as to
472	472	9 not create that significant limitation.
473	473	10 The petitioner bears the burden of demonstrating, by a
474	474	11 preponderance of the credible evidence, that the workers'
475	475	12 compensation maximum fee that would otherwise apply would
476	476	13 create a significant limitation on access to quality
477	477	14 health care in either a specific field of health care
478	478	15 services or a specific geographic limitation on access to
479	479	16 health care. Petitions shall be made publicly available.
480	480	17 Such credible evidence shall include empirical data
481	481	18 demonstrating a significant limitation on access to
482	482	19 quality health care. Other interested persons may file
483	483	20 comments or responses to a petition within 30 days after
484	484	21 the filing of a petition.
485	485	22 The Commission shall take final action on each
486	486	23 petition within 180 days after filing. The Commission may,
487	487	24 but is not required to, seek the recommendation of the
488	488	25 Medical Fee Advisory Board to assist with this
489	489	26 determination. If the Commission grants the petition, the
490	490
491	491
492	492
493	493
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500	500	1 Commission shall further increase the workers'
501	501	2 compensation maximum fee for that CPT or DRG code by the
502	502	3 amount minimally necessary to avoid creating a significant
503	503	4 limitation on access to quality health care in either a
504	504	5 specific field of health care services or a specific
505	505	6 geographic limitation on access to health care. The
506	506	7 increased workers' compensation maximum fee shall take
507	507	8 effect upon entry of the Commission's final action.
508	508	9 (a-2) For procedures, treatments, services, or supplies
509	509	10 covered under this Act and rendered or to be rendered on or
510	510	11 after September 1, 2011, the maximum allowable payment shall
511	511	12 be 70% of the fee schedule amounts, which shall be adjusted
512	512	13 yearly by the Consumer Price Index-U, as described in
513	513	14 subsection (a) of this Section. The provisions of this
514	514	15 subsection (a-2), other than this sentence, are inoperative
515	515	16 after August 31, 2026.
516	516	17 (a-3) Prescriptions filled and dispensed outside of a
517	517	18 licensed pharmacy shall be subject to a fee schedule that
518	518	19 shall not exceed the Average Wholesale Price (AWP) plus a
519	519	20 dispensing fee of $4.18. AWP or its equivalent as registered
520	520	21 by the National Drug Code shall be set forth for that drug on
521	521	22 that date as published in Medispan.
522	522	23 (b) Notwithstanding the provisions of subsection (a), if
523	523	24 the Commission finds that there is a significant limitation on
524	524	25 access to quality health care in either a specific field of
525	525	26 health care services or a specific geographic limitation on
526	526
527	527
528	528
529	529
530	530
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532	532
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536	536	1 access to health care, it may change the Consumer Price
537	537	2 Index-U increase or decrease for that specific field or
538	538	3 specific geographic limitation on access to health care to
539	539	4 address that limitation.
540	540	5 (c) The Commission shall establish by rule a process to
541	541	6 review those medical cases or outliers that involve
542	542	7 extra-ordinary treatment to determine whether to make an
543	543	8 additional adjustment to the maximum payment within a fee
544	544	9 schedule for a procedure, treatment, or service.
545	545	10 (d) When a patient notifies a provider that the treatment,
546	546	11 procedure, or service being sought is for a work-related
547	547	12 illness or injury and furnishes the provider the name and
548	548	13 address of the responsible employer, the provider shall bill
549	549	14 the employer or its designee directly. The employer or its
550	550	15 designee shall make payment for treatment in accordance with
551	551	16 the provisions of this Section directly to the provider,
552	552	17 except that, if a provider has designated a third-party
553	553	18 billing entity to bill on its behalf, payment shall be made
554	554	19 directly to the billing entity. Providers shall submit bills
555	555	20 and records in accordance with the provisions of this Section.
556	556	21 (1) All payments to providers for treatment provided
557	557	22 pursuant to this Act shall be made within 30 days of
558	558	23 receipt of the bills as long as the bill contains
559	559	24 substantially all the required data elements necessary to
560	560	25 adjudicate the bill.
561	561	26 (2) If the bill does not contain substantially all the
562	562
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565	565
566	566
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568	568
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572	572	1 required data elements necessary to adjudicate the bill,
573	573	2 or the claim is denied for any other reason, in whole or in
574	574	3 part, the employer or insurer shall provide written
575	575	4 notification to the provider in the form of an explanation
576	576	5 of benefits explaining the basis for the denial and
577	577	6 describing any additional necessary data elements within
578	578	7 30 days of receipt of the bill. The Commission, with
579	579	8 assistance from the Medical Fee Advisory Board, shall
580	580	9 adopt rules detailing the requirements for the explanation
581	581	10 of benefits required under this subsection.
582	582	11 (3) In the case (i) of nonpayment to a provider within
583	583	12 30 days of receipt of the bill which contained
584	584	13 substantially all of the required data elements necessary
585	585	14 to adjudicate the bill, (ii) of nonpayment to a provider
586	586	15 of a portion of such a bill, or (iii) where the provider
587	587	16 has not been issued an explanation of benefits for a bill,
588	588	17 the bill, or portion of the bill up to the lesser of the
589	589	18 actual charge or the payment level set by the Commission
590	590	19 in the fee schedule established in this Section, shall
591	591	20 incur interest at a rate of 1% per month payable by the
592	592	21 employer to the provider. Any required interest payments
593	593	22 shall be made by the employer or its insurer to the
594	594	23 provider within 30 days after payment of the bill.
595	595	24 (4) If the employer or its insurer fails to pay
596	596	25 interest within 30 days after payment of the bill as
597	597	26 required pursuant to paragraph (3), the provider may bring
598	598
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604	604
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608	608	1 an action in circuit court for the sole purpose of seeking
609	609	2 payment of interest pursuant to paragraph (3) against the
610	610	3 employer or its insurer responsible for insuring the
611	611	4 employer's liability pursuant to item (3) of subsection
612	612	5 (a) of Section 4. The circuit court's jurisdiction shall
613	613	6 be limited to enforcing payment of interest pursuant to
614	614	7 paragraph (3). Interest under paragraph (3) is only
615	615	8 payable to the provider. An employee is not responsible
616	616	9 for the payment of interest under this Section. The right
617	617	10 to interest under paragraph (3) shall not delay, diminish,
618	618	11 restrict, or alter in any way the benefits to which the
619	619	12 employee or his or her dependents are entitled under this
620	620	13 Act.
621	621	14 The changes made to this subsection (d) by this amendatory
622	622	15 Act of the 100th General Assembly apply to procedures,
623	623	16 treatments, and services rendered on and after the effective
624	624	17 date of this amendatory Act of the 100th General Assembly.
625	625	18 (e) Except as provided in subsections (e-5), (e-10), and
626	626	19 (e-15), a provider shall not hold an employee liable for costs
627	627	20 related to a non-disputed procedure, treatment, or service
628	628	21 rendered in connection with a compensable injury. The
629	629	22 provisions of subsections (e-5), (e-10), (e-15), and (e-20)
630	630	23 shall not apply if an employee provides information to the
631	631	24 provider regarding participation in a group health plan. If
632	632	25 the employee participates in a group health plan, the provider
633	633	26 may submit a claim for services to the group health plan. If
634	634
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636	636
637	637
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644	644	1 the claim for service is covered by the group health plan, the
645	645	2 employee's responsibility shall be limited to applicable
646	646	3 deductibles, co-payments, or co-insurance. Except as provided
647	647	4 under subsections (e-5), (e-10), (e-15), and (e-20), a
648	648	5 provider shall not bill or otherwise attempt to recover from
649	649	6 the employee the difference between the provider's charge and
650	650	7 the amount paid by the employer or the insurer on a compensable
651	651	8 injury, or for medical services or treatment determined by the
652	652	9 Commission to be excessive or unnecessary.
653	653	10 (e-5) If an employer notifies a provider that the employer
654	654	11 does not consider the illness or injury to be compensable
655	655	12 under this Act, the provider may seek payment of the
656	656	13 provider's actual charges from the employee for any procedure,
657	657	14 treatment, or service rendered. Once an employee informs the
658	658	15 provider that there is an application filed with the
659	659	16 Commission to resolve a dispute over payment of such charges,
660	660	17 the provider shall cease any and all efforts to collect
661	661	18 payment for the services that are the subject of the dispute.
662	662	19 Any statute of limitations or statute of repose applicable to
663	663	20 the provider's efforts to collect payment from the employee
664	664	21 shall be tolled from the date that the employee files the
665	665	22 application with the Commission until the date that the
666	666	23 provider is permitted to resume collection efforts under the
667	667	24 provisions of this Section.
668	668	25 (e-10) If an employer notifies a provider that the
669	669	26 employer will pay only a portion of a bill for any procedure,
670	670
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673	673
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680	680	1 treatment, or service rendered in connection with a
681	681	2 compensable illness or disease, the provider may seek payment
682	682	3 from the employee for the remainder of the amount of the bill
683	683	4 up to the lesser of the actual charge, negotiated rate, if
684	684	5 applicable, or the payment level set by the Commission in the
685	685	6 fee schedule established in this Section. Once an employee
686	686	7 informs the provider that there is an application filed with
687	687	8 the Commission to resolve a dispute over payment of such
688	688	9 charges, the provider shall cease any and all efforts to
689	689	10 collect payment for the services that are the subject of the
690	690	11 dispute. Any statute of limitations or statute of repose
691	691	12 applicable to the provider's efforts to collect payment from
692	692	13 the employee shall be tolled from the date that the employee
693	693	14 files the application with the Commission until the date that
694	694	15 the provider is permitted to resume collection efforts under
695	695	16 the provisions of this Section.
696	696	17 (e-15) When there is a dispute over the compensability of
697	697	18 or amount of payment for a procedure, treatment, or service,
698	698	19 and a case is pending or proceeding before an Arbitrator or the
699	699	20 Commission, the provider may mail the employee reminders that
700	700	21 the employee will be responsible for payment of any procedure,
701	701	22 treatment or service rendered by the provider. The reminders
702	702	23 must state that they are not bills, to the extent practicable
703	703	24 include itemized information, and state that the employee need
704	704	25 not pay until such time as the provider is permitted to resume
705	705	26 collection efforts under this Section. The reminders shall not
706	706
707	707
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716	716	1 be provided to any credit rating agency. The reminders may
717	717	2 request that the employee furnish the provider with
718	718	3 information about the proceeding under this Act, such as the
719	719	4 file number, names of parties, and status of the case. If an
720	720	5 employee fails to respond to such request for information or
721	721	6 fails to furnish the information requested within 90 days of
722	722	7 the date of the reminder, the provider is entitled to resume
723	723	8 any and all efforts to collect payment from the employee for
724	724	9 the services rendered to the employee and the employee shall
725	725	10 be responsible for payment of any outstanding bills for a
726	726	11 procedure, treatment, or service rendered by a provider.
727	727	12 (e-20) Upon a final award or judgment by an Arbitrator or
728	728	13 the Commission, or a settlement agreed to by the employer and
729	729	14 the employee, a provider may resume any and all efforts to
730	730	15 collect payment from the employee for the services rendered to
731	731	16 the employee and the employee shall be responsible for payment
732	732	17 of any outstanding bills for a procedure, treatment, or
733	733	18 service rendered by a provider as well as the interest awarded
734	734	19 under subsection (d) of this Section. In the case of a
735	735	20 procedure, treatment, or service deemed compensable, the
736	736	21 provider shall not require a payment rate, excluding the
737	737	22 interest provisions under subsection (d), greater than the
738	738	23 lesser of the actual charge or the payment level set by the
739	739	24 Commission in the fee schedule established in this Section.
740	740	25 Payment for services deemed not covered or not compensable
741	741	26 under this Act is the responsibility of the employee unless a
742	742
743	743
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746	746
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748	748
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752	752	1 provider and employee have agreed otherwise in writing.
753	753	2 Services not covered or not compensable under this Act are not
754	754	3 subject to the fee schedule in this Section.
755	755	4 (f) Nothing in this Act shall prohibit an employer or
756	756	5 insurer from contracting with a health care provider or group
757	757	6 of health care providers for reimbursement levels for benefits
758	758	7 under this Act different from those provided in this Section.
759	759	8 (g) On or before January 1, 2010 the Commission shall
760	760	9 provide to the Governor and General Assembly a report
761	761	10 regarding the implementation of the medical fee schedule and
762	762	11 the index used for annual adjustment to that schedule as
763	763	12 described in this Section.
764	764	13 (Source: P.A. 100-1117, eff. 11-27-18; 100-1175, eff.
765	765	14 1-11-19.)
766	766
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