101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
HB2587

 

Introduced , by Rep. Thomas M. Bennett

 

SYNOPSIS AS INTRODUCED:
 
820 ILCS 305/8.2

    Amends the Workers' Compensation Act. Requires a recipient of certain pain management medication to sign a written agreement with the prescribing physician agreeing to comply with the conditions of the prescription. Prohibits additional prescriptions while the recipient is noncompliant. Limits the applicability of the lack of pain management as a consideration in awarding benefits. Provides for the disclosure of violations of the agreement upon request by the employer. Requires a prescribing physician to file quarterly reports to obtain payment. Effective immediately.


LRB101 08368 JLS 53437 b

 

 

A BILL FOR

 

HB2587LRB101 08368 JLS 53437 b

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 Medi-Span Medispan.
15    (a-4) As a condition of receiving pain management that
16requires prescribing a Schedule II, III, or IV controlled
17substance, as provided in the Illinois Controlled Substances
18Act, the injured worker shall sign a formal written agreement
19with the physician prescribing the Schedule II, III, or IV
20controlled substance acknowledging the conditions under which
21the injured worker shall continue to be prescribed a Schedule
22II, III, or IV controlled substance and agreeing to comply with
23those conditions. The pain management agreement shall outline
24the risks and benefits of opioid use, the conditions under
25which opioids will be prescribed, and the responsibilities of
26the prescribing physician and the injured worker.

 

 

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1    An agreement made pursuant to this subsection shall be
2reviewed, updated, and renewed every 6 months.
3    (a-4.1) If the injured worker violates any of the
4conditions of the agreement on more than one occasion, the
5injured worker's right to pain management through the
6prescription of a Schedule II, III, or IV controlled substance
7under this Act shall be suspended pursuant to subsection (d) of
8Section 19 of this Act until the injured worker becomes
9compliant with the pain management agreement.
10    (a-4.2) A physician may disclose the employee's violation
11of the formal written agreement on the physician's own
12initiative. Upon request of the employer, a physician shall
13disclose the employee's violation of the formal written
14agreement provided in this Section.
15    (a-4.3) The formal written agreement shall include a notice
16disclosing to the employee in capitalized, conspicuous
17lettering on the face of the agreement the consequences for
18violating the terms of the agreement as provided for in this
19Section.
20    (a-4.4) If an injured worker's pain management benefits are
21terminated pursuant to alleged violations of the formal
22agreement as provided in this Section, the employee may file a
23request for an expedited hearing pursuant to subsection (b) of
24Section 19 of this Act.
25    (a-4.5) Any prescribing physician requiring a written
26agreement with an injured worker pursuant to this Section shall

 

 

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1have a rebuttable presumption of non-liability under Part 17 of
2Article II of the Code of Civil Procedure for injuries caused
3by the lack of access to Schedule II, III, or IV controlled
4substances if a violation of the agreement results in
5termination of pain management benefits pursuant to this
6Section.
7    (a-5) As used in this Section, "chronic pain" means pain
8that is unrelated to cancer, that is incident to surgery, and
9that persists beyond the period of expected healing after an
10acute injury episode or is pain that persists beyond 180 days
11following the onset of the pain.
12    (a-5.1) To receive reimbursement for a Schedule II, III, or
13IV controlled substance for chronic pain, the physician seeking
14reimbursement shall submit a written report to the payer not
15later than 90 days after the initial Schedule II, III, or IV
16controlled substance prescription fill for chronic pain and
17every 90 days thereafter. The written report shall include all
18of the following:
19        (1) A review and analysis of the relevant prior medical
20    history, including any consultations that have been
21    obtained and a review of data received from an automated
22    prescription drug monitoring program in the treating
23    jurisdiction for identification of past history of
24    narcotic use and any concurrent prescriptions.
25        (2) A summary of conservative care rendered to the
26    injured worker that focused on increased function and

 

 

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1    return to work.
2        (3) A statement on why prior or alternative
3    conservative measures were ineffective or contraindicated.
4        (4) A statement that the attending physician has
5    considered the results obtained from appropriate
6    industry-accepted screening tools to detect factors that
7    may significantly increase the risk of abuse or adverse
8    outcomes including a history of alcohol or other substance
9    abuse.
10        (5) A treatment plan which includes all of the
11    following:
12            (A) Overall treatment goals, functional progress,
13        and demonstrated progress.
14            (B) Periodic urine drug screens.
15            (C) A conscientious effort to reduce pain through
16        the use of non-opioid medications, alternative
17        non-pharmaceutical strategies, or both.
18            (D) Consideration of weaning the injured or
19        disabled patient from opioid use including, but not
20        limited to, detoxification.
21    (a-5.2) A provider may bill the additional services
22required for compliance with this Section utilizing CPT
23procedure code 99215 for the initial 90-day report and all
24subsequent follow-up reports at 90-day intervals.
25    (a-5.3) A payor is not required to reimburse and the
26injured worker is not liable for the chronic pain services if

 

 

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1the physician reporting and treatment plan requirements
2pursuant to subsection (a-5.1) are not met. If the injured
3worker is in the process of weaning or weaning has been
4approved by the payor, denial of reimbursement shall occur only
5after a period of time, as established by evidence-based
6medicine and national guidelines, is provided for the weaning
7of the injured worker from the Schedule II, III, or IV
8controlled substance medication or alternative means of pain
9management have been offered.
10    (a-6) A payor who denies benefits in compliance with
11subsection (a-4.1) or subsection (a-5.3), performs utilization
12review as provided in Section 8.7, and finds the care to be
13inconsistent with national guidelines and protocols and that
14the prescriber failed to respond to the utilization review
15determination with a variance from the standards of care used
16in the utilization review that justifies the care is reasonably
17required and necessary to cure or relieve the effects of his or
18her injury, is rebuttably presumed to have acted in good faith
19and not subject to penalties under subsections (k) and (l) of
20Section 19.
21    (b) Notwithstanding the provisions of subsection (a), if
22the Commission finds that there is a significant limitation on
23access to quality health care in either a specific field of
24health care services or a specific geographic limitation on
25access to health care, it may change the Consumer Price Index-U
26increase or decrease for that specific field or specific

 

 

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1geographic limitation on access to health care to address that
2limitation.
3    (c) The Commission shall establish by rule a process to
4review those medical cases or outliers that involve
5extra-ordinary treatment to determine whether to make an
6additional adjustment to the maximum payment within a fee
7schedule for a procedure, treatment, or service.
8    (d) When a patient notifies a provider that the treatment,
9procedure, or service being sought is for a work-related
10illness or injury and furnishes the provider the name and
11address of the responsible employer, the provider shall bill
12the employer or its designee directly. The employer or its
13designee shall make payment for treatment in accordance with
14the provisions of this Section directly to the provider, except
15that, if a provider has designated a third-party billing entity
16to bill on its behalf, payment shall be made directly to the
17billing entity. Providers shall submit bills and records in
18accordance with the provisions of this Section.
19        (1) All payments to providers for treatment provided
20    pursuant to this Act shall be made within 30 days of
21    receipt of the bills as long as the bill contains
22    substantially all the required data elements necessary to
23    adjudicate the bill.
24        (2) If the bill does not contain substantially all the
25    required data elements necessary to adjudicate the bill, or
26    the claim is denied for any other reason, in whole or in

 

 

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1    part, the employer or insurer shall provide written
2    notification to the provider in the form of an explanation
3    of benefits explaining the basis for the denial and
4    describing any additional necessary data elements within
5    30 days of receipt of the bill. The Commission, with
6    assistance from the Medical Fee Advisory Board, shall adopt
7    rules detailing the requirements for the explanation of
8    benefits required under this subsection.
9        (3) In the case (i) of nonpayment to a provider within
10    30 days of receipt of the bill which contained
11    substantially all of the required data elements necessary
12    to adjudicate the bill, (ii) of nonpayment to a provider of
13    a portion of such a bill, or (iii) where the provider has
14    not been issued an explanation of benefits for a bill, the
15    bill, or portion of the bill up to the lesser of the actual
16    charge or the payment level set by the Commission in the
17    fee schedule established in this Section, shall incur
18    interest at a rate of 1% per month payable by the employer
19    to the provider. Any required interest payments shall be
20    made by the employer or its insurer to the provider within
21    30 days after payment of the bill.
22        (4) If the employer or its insurer fails to pay
23    interest within 30 days after payment of the bill as
24    required pursuant to paragraph (3), the provider may bring
25    an action in circuit court for the sole purpose of seeking
26    payment of interest pursuant to paragraph (3) against the

 

 

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1    employer or its insurer responsible for insuring the
2    employer's liability pursuant to item (3) of subsection (a)
3    of Section 4. The circuit court's jurisdiction shall be
4    limited to enforcing payment of interest pursuant to
5    paragraph (3). Interest under paragraph (3) is only payable
6    to the provider. An employee is not responsible for the
7    payment of interest under this Section. The right to
8    interest under paragraph (3) shall not delay, diminish,
9    restrict, or alter in any way the benefits to which the
10    employee or his or her dependents are entitled under this
11    Act.
12    The changes made to this subsection (d) by this amendatory
13Act of the 100th General Assembly apply to procedures,
14treatments, and services rendered on and after the effective
15date of this amendatory Act of the 100th General Assembly.
16    (e) Except as provided in subsections (e-5), (e-10), and
17(e-15), a provider shall not hold an employee liable for costs
18related to a non-disputed procedure, treatment, or service
19rendered in connection with a compensable injury. The
20provisions of subsections (e-5), (e-10), (e-15), and (e-20)
21shall not apply if an employee provides information to the
22provider regarding participation in a group health plan. If the
23employee participates in a group health plan, the provider may
24submit a claim for services to the group health plan. If the
25claim for service is covered by the group health plan, the
26employee's responsibility shall be limited to applicable

 

 

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

 

 

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1actual charge, negotiated rate, if applicable, or the payment
2level set by the Commission in the fee schedule established in
3this Section. Once an employee informs the provider that there
4is an application filed with the Commission to resolve a
5dispute over payment of such charges, the provider shall cease
6any and all efforts to collect payment for the services that
7are the subject of the dispute. Any statute of limitations or
8statute of repose applicable to the provider's efforts to
9collect payment from the employee shall be tolled from the date
10that the employee files the application with the Commission
11until the date that the provider is permitted to resume
12collection efforts under the provisions of this Section.
13    (e-15) When there is a dispute over the compensability of
14or amount of payment for a procedure, treatment, or service,
15and a case is pending or proceeding before an Arbitrator or the
16Commission, the provider may mail the employee reminders that
17the employee will be responsible for payment of any procedure,
18treatment or service rendered by the provider. The reminders
19must state that they are not bills, to the extent practicable
20include itemized information, and state that the employee need
21not pay until such time as the provider is permitted to resume
22collection efforts under this Section. The reminders shall not
23be provided to any credit rating agency. The reminders may
24request that the employee furnish the provider with information
25about the proceeding under this Act, such as the file number,
26names of parties, and status of the case. If an employee fails

 

 

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1to respond to such request for information or fails to furnish
2the information requested within 90 days of the date of the
3reminder, the provider is entitled to resume any and all
4efforts to collect payment from the employee for the services
5rendered to the employee and the employee shall be responsible
6for payment of any outstanding bills for a procedure,
7treatment, or service rendered by a provider.
8    (e-20) Upon a final award or judgment by an Arbitrator or
9the Commission, or a settlement agreed to by the employer and
10the employee, a provider may resume any and all efforts to
11collect payment from the employee for the services rendered to
12the employee and the employee shall be responsible for payment
13of any outstanding bills for a procedure, treatment, or service
14rendered by a provider as well as the interest awarded under
15subsection (d) of this Section. In the case of a procedure,
16treatment, or service deemed compensable, the provider shall
17not require a payment rate, excluding the interest provisions
18under subsection (d), greater than the lesser of the actual
19charge or the payment level set by the Commission in the fee
20schedule established in this Section. Payment for services
21deemed not covered or not compensable under this Act is the
22responsibility of the employee unless a provider and employee
23have agreed otherwise in writing. Services not covered or not
24compensable under this Act are not subject to the fee schedule
25in this Section.
26    (f) Nothing in this Act shall prohibit an employer or

 

 

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1insurer from contracting with a health care provider or group
2of health care providers for reimbursement levels for benefits
3under this Act different from those provided in this Section.
4    (g) On or before January 1, 2010 the Commission shall
5provide to the Governor and General Assembly a report regarding
6the implementation of the medical fee schedule and the index
7used for annual adjustment to that schedule as described in
8this Section.
9(Source: P.A. 100-1117, eff. 11-27-18; 100-1175, eff.
101-11-19.)
 
11    Section 99. Effective date. This Act takes effect upon
12becoming law.