Bill Text: IL SB1660 | 2017-2018 | 100th General Assembly | Introduced


Bill Title: Amends the Workers' Compensation Act. Provides that no medical provider shall be reimbursed for a supply of prescriptions filled outside of a licensed pharmacy except when there exists no licensed pharmacy within 5 miles of the prescribing physician's practice. Provides that, if there exists no licensed pharmacy within 5 miles of the prescribing physician's practice, no medical provider shall be reimbursed for a prescription, the supply of which lasts for longer than 72 hours from the date of injury or 24 hours from the date of first referral to the medical service provider, whichever is greater, filled and dispensed outside of a licensed pharmacy. Provides that the limitations on filling and dispensing prescriptions do not apply if there exists a pre-arranged agreement between the medical provider and a preferred provider program regarding the filling of prescriptions outside a licensed pharmacy.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced) 2017-05-05 - Rule 3-9(a) / Re-referred to Assignments [SB1660 Detail]

Download: Illinois-2017-SB1660-Introduced.html


100TH GENERAL ASSEMBLY
State of Illinois
2017 and 2018
SB1660

Introduced 2/9/2017, by Sen. Kyle McCarter

SYNOPSIS AS INTRODUCED:
820 ILCS 305/8.2

Amends the Workers' Compensation Act. Provides that no medical provider shall be reimbursed for a supply of prescriptions filled outside of a licensed pharmacy except when there exists no licensed pharmacy within 5 miles of the prescribing physician's practice. Provides that, if there exists no licensed pharmacy within 5 miles of the prescribing physician's practice, no medical provider shall be reimbursed for a prescription, the supply of which lasts for longer than 72 hours from the date of injury or 24 hours from the date of first referral to the medical service provider, whichever is greater, filled and dispensed outside of a licensed pharmacy. Provides that the limitations on filling and dispensing prescriptions do not apply if there exists a pre-arranged agreement between the medical provider and a preferred provider program regarding the filling of prescriptions outside a licensed pharmacy.
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A BILL FOR

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1 AN ACT concerning employment.
2 Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4 Section 5. The Workers' Compensation Act is amended by
5changing Section 8.2 as follows:
6 (820 ILCS 305/8.2)
7 Sec. 8.2. Fee schedule.
8 (a) Except as provided for in subsection (c), for
9procedures, treatments, or services covered under this Act and
10rendered or to be rendered on and after February 1, 2006, the
11maximum allowable payment shall be 90% of the 80th percentile
12of charges and fees as determined by the Commission utilizing
13information provided by employers' and insurers' national
14databases, with a minimum of 12,000,000 Illinois line item
15charges and fees comprised of health care provider and hospital
16charges and fees as of August 1, 2004 but not earlier than
17August 1, 2002. These charges and fees are provider billed
18amounts and shall not include discounted charges. The 80th
19percentile is the point on an ordered data set from low to high
20such that 80% of the cases are below or equal to that point and
21at most 20% are above or equal to that point. The Commission
22shall adjust these historical charges and fees as of August 1,
232004 by the Consumer Price Index-U for the period August 1,

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12004 through September 30, 2005. The Commission shall establish
2fee schedules for procedures, treatments, or services for
3hospital inpatient, hospital outpatient, emergency room and
4trauma, ambulatory surgical treatment centers, and
5professional services. These charges and fees shall be
6designated by geozip or any smaller geographic unit. The data
7shall in no way identify or tend to identify any patient,
8employer, or health care provider. As used in this Section,
9"geozip" means a three-digit zip code based on data
10similarities, geographical similarities, and frequencies. A
11geozip does not cross state boundaries. As used in this
12Section, "three-digit zip code" means a geographic area in
13which all zip codes have the same first 3 digits. If a geozip
14does not have the necessary number of charges and fees to
15calculate a valid percentile for a specific procedure,
16treatment, or service, the Commission may combine data from the
17geozip with up to 4 other geozips that are demographically and
18economically similar and exhibit similarities in data and
19frequencies until the Commission reaches 9 charges or fees for
20that specific procedure, treatment, or service. In cases where
21the compiled data contains less than 9 charges or fees for a
22procedure, treatment, or service, reimbursement shall occur at
2376% of charges and fees as determined by the Commission in a
24manner consistent with the provisions of this paragraph.
25Providers of out-of-state procedures, treatments, services,
26products, or supplies shall be reimbursed at the lesser of that

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1state's fee schedule amount or the fee schedule amount for the
2region in which the employee resides. If no fee schedule exists
3in that state, the provider shall be reimbursed at the lesser
4of the actual charge or the fee schedule amount for the region
5in which the employee resides. Not later than September 30 in
62006 and each year thereafter, the Commission shall
7automatically increase or decrease the maximum allowable
8payment for a procedure, treatment, or service established and
9in effect on January 1 of that year by the percentage change in
10the Consumer Price Index-U for the 12 month period ending
11August 31 of that year. The increase or decrease shall become
12effective on January 1 of the following year. As used in this
13Section, "Consumer Price Index-U" means the index published by
14the Bureau of Labor Statistics of the U.S. Department of Labor,
15that measures the average change in prices of all goods and
16services purchased by all urban consumers, U.S. city average,
17all items, 1982-84=100.
18 (a-1) Notwithstanding the provisions of subsection (a) and
19unless otherwise indicated, the following provisions shall
20apply to the medical fee schedule starting on September 1,
212011:
22 (1) The Commission shall establish and maintain fee
23 schedules for procedures, treatments, products, services,
24 or supplies for hospital inpatient, hospital outpatient,
25 emergency room, ambulatory surgical treatment centers,
26 accredited ambulatory surgical treatment facilities,

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1 prescriptions filled and dispensed outside of a licensed
2 pharmacy, dental services, and professional services. This
3 fee schedule shall be based on the fee schedule amounts
4 already established by the Commission pursuant to
5 subsection (a) of this Section. However, starting on
6 January 1, 2012, these fee schedule amounts shall be
7 grouped into geographic regions in the following manner:
8 (A) Four regions for non-hospital fee schedule
9 amounts shall be utilized:
10 (i) Cook County;
11 (ii) DuPage, Kane, Lake, and Will Counties;
12 (iii) Bond, Calhoun, Clinton, Jersey,
13 Macoupin, Madison, Monroe, Montgomery, Randolph,
14 St. Clair, and Washington Counties; and
15 (iv) All other counties of the State.
16 (B) Fourteen regions for hospital fee schedule
17 amounts shall be utilized:
18 (i) Cook, DuPage, Will, Kane, McHenry, DeKalb,
19 Kendall, and Grundy Counties;
20 (ii) Kankakee County;
21 (iii) Madison, St. Clair, Macoupin, Clinton,
22 Monroe, Jersey, Bond, and Calhoun Counties;
23 (iv) Winnebago and Boone Counties;
24 (v) Peoria, Tazewell, Woodford, Marshall, and
25 Stark Counties;
26 (vi) Champaign, Piatt, and Ford Counties;

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1 (vii) Rock Island, Henry, and Mercer Counties;
2 (viii) Sangamon and Menard Counties;
3 (ix) McLean County;
4 (x) Lake County;
5 (xi) Macon County;
6 (xii) Vermilion County;
7 (xiii) Alexander County; and
8 (xiv) All other counties of the State.
9 (2) If a geozip, as defined in subsection (a) of this
10 Section, overlaps into one or more of the regions set forth
11 in this Section, then the Commission shall average or
12 repeat the charges and fees in a geozip in order to
13 designate charges and fees for each region.
14 (3) In cases where the compiled data contains less than
15 9 charges or fees for a procedure, treatment, product,
16 supply, or service or where the fee schedule amount cannot
17 be determined by the non-discounted charge data,
18 non-Medicare relative values and conversion factors
19 derived from established fee schedule amounts, coding
20 crosswalks, or other data as determined by the Commission,
21 reimbursement shall occur at 76% of charges and fees until
22 September 1, 2011 and 53.2% of charges and fees thereafter
23 as determined by the Commission in a manner consistent with
24 the provisions of this paragraph.
25 (4) To establish additional fee schedule amounts, the
26 Commission shall utilize provider non-discounted charge

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1 data, non-Medicare relative values and conversion factors
2 derived from established fee schedule amounts, and coding
3 crosswalks. The Commission may establish additional fee
4 schedule amounts based on either the charge or cost of the
5 procedure, treatment, product, supply, or service.
6 (5) Implants shall be reimbursed at 25% above the net
7 manufacturer's invoice price less rebates, plus actual
8 reasonable and customary shipping charges whether or not
9 the implant charge is submitted by a provider in
10 conjunction with a bill for all other services associated
11 with the implant, submitted by a provider on a separate
12 claim form, submitted by a distributor, or submitted by the
13 manufacturer of the implant. "Implants" include the
14 following codes or any substantially similar updated code
15 as determined by the Commission: 0274
16 (prosthetics/orthotics); 0275 (pacemaker); 0276 (lens
17 implant); 0278 (implants); 0540 and 0545 (ambulance); 0624
18 (investigational devices); and 0636 (drugs requiring
19 detailed coding). Non-implantable devices or supplies
20 within these codes shall be reimbursed at 65% of actual
21 charge, which is the provider's normal rates under its
22 standard chargemaster. A standard chargemaster is the
23 provider's list of charges for procedures, treatments,
24 products, supplies, or services used to bill payers in a
25 consistent manner.
26 (6) The Commission shall automatically update all

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1 codes and associated rules with the version of the codes
2 and rules valid on January 1 of that year.
3 (a-2) For procedures, treatments, services, or supplies
4covered under this Act and rendered or to be rendered on or
5after September 1, 2011, the maximum allowable payment shall be
670% of the fee schedule amounts, which shall be adjusted yearly
7by the Consumer Price Index-U, as described in subsection (a)
8of this Section.
9 (a-3) Prescriptions filled and dispensed outside of a
10licensed pharmacy shall be subject to a fee schedule that shall
11not exceed the Average Wholesale Price (AWP) plus a dispensing
12fee of $4.18. AWP or its equivalent as registered by the
13National Drug Code shall be set forth for that drug on that
14date as published in Medispan.
15 (a-4) No medical provider shall be reimbursed under this
16Act for a supply of prescriptions filled and dispensed outside
17of a licensed pharmacy except where there exists no licensed
18pharmacy within 5 miles of the prescribing physician's
19practice.
20 Where there exists no licensed pharmacy within 5 miles of
21the prescribing physician's practice, no medical provider
22shall be reimbursed under this Act for a prescription filled
23and dispensed outside of a licensed pharmacy the supply of
24which lasts for longer than 72 hours from the date of the
25injury or 24 hours from the date of first referral to the
26medical service provider, whichever is greater.

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1 This limitation on filling and dispensing prescriptions
2shall not apply where there exists a pre-arranged agreement
3regarding the filling and dispensing of prescriptions outside a
4licensed pharmacy between the medical provider and a preferred
5provider program pursuant to Section 8.1a on the date that the
6employee sustained his or her injuries.
7 (b) Notwithstanding the provisions of subsection (a), if
8the Commission finds that there is a significant limitation on
9access to quality health care in either a specific field of
10health care services or a specific geographic limitation on
11access to health care, it may change the Consumer Price Index-U
12increase or decrease for that specific field or specific
13geographic limitation on access to health care to address that
14limitation.
15 (c) The Commission shall establish by rule a process to
16review those medical cases or outliers that involve
17extra-ordinary treatment to determine whether to make an
18additional adjustment to the maximum payment within a fee
19schedule for a procedure, treatment, or service.
20 (d) When a patient notifies a provider that the treatment,
21procedure, or service being sought is for a work-related
22illness or injury and furnishes the provider the name and
23address of the responsible employer, the provider shall bill
24the employer directly. The employer shall make payment and
25providers shall submit bills and records in accordance with the
26provisions of this Section.

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1 (1) All payments to providers for treatment provided
2 pursuant to this Act shall be made within 30 days of
3 receipt of the bills as long as the claim contains
4 substantially all the required data elements necessary to
5 adjudicate the bills.
6 (2) If the claim does not contain substantially all the
7 required data elements necessary to adjudicate the bill, or
8 the claim is denied for any other reason, in whole or in
9 part, the employer or insurer shall provide written
10 notification, explaining the basis for the denial and
11 describing any additional necessary data elements, to the
12 provider within 30 days of receipt of the bill.
13 (3) In the case of nonpayment to a provider within 30
14 days of receipt of the bill which contained substantially
15 all of the required data elements necessary to adjudicate
16 the bill or nonpayment to a provider of a portion of such a
17 bill up to the lesser of the actual charge or the payment
18 level set by the Commission in the fee schedule established
19 in this Section, the bill, or portion of the bill, shall
20 incur interest at a rate of 1% per month payable to the
21 provider. Any required interest payments shall be made
22 within 30 days after payment.
23 (e) Except as provided in subsections (e-5), (e-10), and
24(e-15), a provider shall not hold an employee liable for costs
25related to a non-disputed procedure, treatment, or service
26rendered in connection with a compensable injury. The

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1provisions of subsections (e-5), (e-10), (e-15), and (e-20)
2shall not apply if an employee provides information to the
3provider regarding participation in a group health plan. If the
4employee participates in a group health plan, the provider may
5submit a claim for services to the group health plan. If the
6claim for service is covered by the group health plan, the
7employee's responsibility shall be limited to applicable
8deductibles, co-payments, or co-insurance. Except as provided
9under subsections (e-5), (e-10), (e-15), and (e-20), a provider
10shall not bill or otherwise attempt to recover from the
11employee the difference between the provider's charge and the
12amount paid by the employer or the insurer on a compensable
13injury, or for medical services or treatment determined by the
14Commission to be excessive or unnecessary.
15 (e-5) If an employer notifies a provider that the employer
16does not consider the illness or injury to be compensable under
17this Act, the provider may seek payment of the provider's
18actual charges from the employee for any procedure, treatment,
19or service rendered. Once an employee informs the provider that
20there is an application filed with the Commission to resolve a
21dispute over payment of such charges, the provider shall cease
22any and all efforts to collect payment for the services that
23are the subject of the dispute. Any statute of limitations or
24statute of repose applicable to the provider's efforts to
25collect payment from the employee shall be tolled from the date
26that the employee files the application with the Commission

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1until the date that the provider is permitted to resume
2collection efforts under the provisions of this Section.
3 (e-10) If an employer notifies a provider that the employer
4will pay only a portion of a bill for any procedure, treatment,
5or service rendered in connection with a compensable illness or
6disease, the provider may seek payment from the employee for
7the remainder of the amount of the bill up to the lesser of the
8actual charge, negotiated rate, if applicable, or the payment
9level set by the Commission in the fee schedule established in
10this Section. Once an employee informs the provider that there
11is an application filed with the Commission to resolve a
12dispute over payment of such charges, the provider shall cease
13any and all efforts to collect payment for the services that
14are the subject of the dispute. Any statute of limitations or
15statute of repose applicable to the provider's efforts to
16collect payment from the employee shall be tolled from the date
17that the employee files the application with the Commission
18until the date that the provider is permitted to resume
19collection efforts under the provisions of this Section.
20 (e-15) When there is a dispute over the compensability of
21or amount of payment for a procedure, treatment, or service,
22and a case is pending or proceeding before an Arbitrator or the
23Commission, the provider may mail the employee reminders that
24the employee will be responsible for payment of any procedure,
25treatment or service rendered by the provider. The reminders
26must state that they are not bills, to the extent practicable

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1include itemized information, and state that the employee need
2not pay until such time as the provider is permitted to resume
3collection efforts under this Section. The reminders shall not
4be provided to any credit rating agency. The reminders may
5request that the employee furnish the provider with information
6about the proceeding under this Act, such as the file number,
7names of parties, and status of the case. If an employee fails
8to respond to such request for information or fails to furnish
9the information requested within 90 days of the date of the
10reminder, the provider is entitled to resume any and all
11efforts to collect payment from the employee for the services
12rendered to the employee and the employee shall be responsible
13for payment of any outstanding bills for a procedure,
14treatment, or service rendered by a provider.
15 (e-20) Upon a final award or judgment by an Arbitrator or
16the Commission, or a settlement agreed to by the employer and
17the employee, a provider may resume any and all efforts to
18collect payment from the employee for the services rendered to
19the employee and the employee shall be responsible for payment
20of any outstanding bills for a procedure, treatment, or service
21rendered by a provider as well as the interest awarded under
22subsection (d) of this Section. In the case of a procedure,
23treatment, or service deemed compensable, the provider shall
24not require a payment rate, excluding the interest provisions
25under subsection (d), greater than the lesser of the actual
26charge or the payment level set by the Commission in the fee

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1schedule established in this Section. Payment for services
2deemed not covered or not compensable under this Act is the
3responsibility of the employee unless a provider and employee
4have agreed otherwise in writing. Services not covered or not
5compensable under this Act are not subject to the fee schedule
6in this Section.
7 (f) Nothing in this Act shall prohibit an employer or
8insurer from contracting with a health care provider or group
9of health care providers for reimbursement levels for benefits
10under this Act different from those provided in this Section.
11 (g) On or before January 1, 2010 the Commission shall
12provide to the Governor and General Assembly a report regarding
13the implementation of the medical fee schedule and the index
14used for annual adjustment to that schedule as described in
15this Section.
16(Source: P.A. 97-18, eff. 6-28-11.)
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