The 2011 IL Work Comp Reform The Sound & The Fury. Adam Haight IWIRC Director, Business Development

Transcription

1 The 2011 IL Work Comp Reform The Sound & The Fury Adam Haight IWIRC Director, Business Development

2 Recap: Causation Section 1(d) PPP Networks Section 8.1a IL Work Comp Fee Schedule Section 8.2 Utilization Review Section 8.7 AMA Impairment Rating Section 8.1b Intoxication Section 11 2

3 Burden of Proof - Causation Codifies the definition of an injury. New Section 1(d): To obtain compensation under this Act, an employee bears the burden of showing, by a preponderance of the evidence, that he or she has sustained accidental injuries arising out of and in the course of the employment. Effective June 28,

4 Preferred Provider Program PPA vs. PPP HB 1698 now allows an employer to utilize a Preferred Provider Program (PPP) approved by the Department of Insurance for the direction of medical treatment of injured employees. These new work comp PPPs must comply with all of the existing PPA requirements, plus additional requirements. 4

5 Pre-PPP WC PPO System In Illinois Employers could recommend specific providers to their injured workers, but injured employees could choose any medical provider, and the employers were responsible for all the medical bills. Providers could refer to any facility, specialist, etc, and the employer was responsible for those medical bills. Employees had choices of providers, and all of the resulting referrals from those providers, covered by their employers. *If you do not select a PPP The system remains as is!! 5

6 Fee Schedule Changes (Effective 9/1/11) 30% Reduction in Provider Reimbursement The maximum allowable payments for all listed flat rate codes will be 70% of their current state fee schedule reprice amounts. Codes where a schedule amount cannot be determined, will reimburse at 53.2% of billed charges. 6

7 Miscellaneous Medical Fee Changes Interest on bills at 1% per month after 30 days, not 60. Excessive or unnecessary treatment not payable. Claim must contain substantially all the required data elements necessary to adjudicate the bill. Employer to provide written notice to the provider if claim is denied or additional information is required. 7

8 Fee Schedule Region Changes (Effective 1/1/12) Prior to 1/1/12 for Non-Hospital Facilities: 29 fee schedule Regions: Regions based on the first 3 digits of the providers service location zip code Effective 1/1/2012 8

9 9 4 Non-Hospital Regions 1. Cook County 2. DuPage, Kane, Lake, & Will Counties 3. Bond, Calhoun, Clinton, Jersey, Macoupin, Madison, Monroe, Montgomery, Randolph, St. Clair, & Washington Counties 4. All other counties in the state

10 10 14 Hospital Regions 1. Cook, DuPage, Will, Kane, McHenry, DeKalb, Kendall, & Grundy 2. Kankakee 3. Madison, St. Clair, Macoupin, Clinton, Monroe, Jersey, Bond, & Calhoun 4. Winnebago & Boone 5. Peoria, Tazewell, Woodford, Marshall, & Stark 6. Champaign, Piatt, & Ford 7. Rock Island, Henry, & Mercer 8. Sangamon & Menard 9. McLean 10. Lake 11. Macon 12. Vermilion 13. Alexander 14. All other counties in the state

11 Fee Schedule Changes (Effective 7/16/14) On July 16, 2014, the Illinois Workers' Compensation Commission (IWCC) voted unanimously to raise reimbursement rates for nonsurgical evaluation and management (E&M) CPT codes on the Workers' Compensation Fee Schedule. The Workers' Compensation Act authorizes the Commission to increase fee schedule amounts when it finds there is a significant limitation on injured workers' access to medical care; the ISMS and individual physicians successfully demonstrated that low fees for E&M services - the lowest in the nation by some estimates - seriously hindered patient access to needed care. s ISMS_Successful_in_Obtaining_Increased_Reimbursement_for_Illinois_Workers_Comp/ 11

12 Utilization Review The evaluation of proposed or provided health care services to determine the appropriateness of both the level of health care services medically necessary and the quality of health care services provided to a patient, including evaluation of their efficiency, efficacy, and appropriateness of treatment, hospitalization, or office visits based on medically accepted standards. The evaluation must be accomplished by means of a system that identifies the utilization of health care services based on standards of care of nationally recognized peer review guidelines as well as nationally recognized treatment guidelines and evidence-based medicine based upon standards as provided in this Act. ODG Official Disability Guidelines 12

13 Utilization Review (continued) Utilization review program must be registered with the Illinois Department of Insurance. Medical provider shall provide to UR timely and complete reports needed to support a request for treatment. If provider fails to make reasonable efforts to provide information, bills, may not be compensable nor collectable. Written notice of UR decision to be provided to provider and employee. Employee has burden of proof to show by a preponderance of the evidence that a variance from the standard of care is reasonably required to cure effects of his or her injury. Applies to Health Care Services provided or proposed to be provided on or after September 1,

14 AMA Guides - Impairment A physician preparing a permanent partial disability impairment report shall report the level of impairment in writing. The report shall include the level of impairment that includes...: loss of range of motion; loss of strength; measured atrophy ; and any other measurements that establish the nature and extent of impairment. Most current edition of the American Medical Association s Guides to the Evaluation of Permanent Impairment shall be used According to AMA guidelines, pain is not a factor in determining impairment 14

15 Establishing Permanent Partial Disability In determining the level of permanent partial disability, the Commission shall base its determination on the following factors: the reported level of impairment pursuant to subsection (a); the occupation of the injured employee; the age of the employee at the time of the injury; the employee's future earning capacity; evidence of disability corroborated by the treating medical records. No single enumerated factor shall be the sole determinant of disability. In determining the level of disability, the relevance and weight of any factors used in addition to the level of impairment as reported by the physician must be explained in a written order.

16 Intoxication No compensation shall be payable if the employee's intoxication is the proximate cause of the employee's accidental injury or at the time the employee incurred the accidental injury, the employee was so intoxicated that the intoxication constituted a departure from the employment. 16

17 Intoxication (continued) The employee may overcome the rebuttable presumption by the preponderance of the admissible evidence that the intoxication was not the sole proximate cause or proximate cause of the accidental injuries. regulations promulgated by the United States Department of Transportation split testing procedures are utilized 17

18 Food for Thought Are you in a PPP? Do you think you should be? Are your employees currently receiving AMA Impairment Ratings? Do you have a Drug Free Workplace Policy and are you actively enforcing that policy? (New OSHA Recordkeeping Rule) 18

19 New WCRI Findings

20 Workers Compensation Premium Over Medicare, March 2016

21 Zooming In

22 Other Factors for High WC Costs in IL Medical payments per claim in Illinois increased annually an average of 3.1 percent between 2012 and 2014, driven primarily by higher payments to ambulatory surgery centers (ASCs), according to a new Workers Compensation Research Institute (WCRI) study. Medical Payments per Claim Dropped After Reduction In Fee Schedule, Then Grew Modestly 2010 to 2012 = -19% (9.7% per year) 2012 to 2013 = +4% 2013 to 2014 = +2% *Why did costs go back up?!

23 Other Factors for High WC Costs in IL cont Medical payments per workers compensation claim in Illinois remained higher than the other states we examined but have moved closer to the median study state, and the shift can be attributed in part to the state s 2011 reforms, said Ramona Tanabe, WCRI s executive vice president and counsel. The following are among the report s other findings: Medical payments per workers compensation claim for services provided by physicians, physical/occupational therapists, and chiropractors remained higher in Illinois than in other study states. Illinois had the highest utilization of medical services among the study states, driven by physical medicine services. Medical payments per claim to hospitals, for both outpatient and inpatient care, were similar in Illinois to other study states.

24 Other Factors for High WC Costs in IL cont IL Had Higher Defense Attorney Involvement (41%) & Among Lowest Payments Per Claim >$500 ($4,048) IL Non-Hospital Payments per Claim Higher Than Median State, Except for E&M Percent of Workers Receiving Physical Therapy in IL Higher Than Most Study States Median 69%, IL 73% More PT visits per Claim in IL Median 23 visits, IL 31 visits

25 Other Factors for High WC Costs in IL cont IL Injured Workers Stayed Off Work Longer Than Other Study States Higher % of claims w/ Lump-Sum Settlements & higher PPD/Lump-Sum Payments per Claim PPD and/or Lump-Sum benefits are based on several factors in addition to physical impairment (AMA Rating) Higher TTD benefits per claim Higher TTD Weekly Amounts; Maximum TTD Benefit Based on 133 1/3% of SAWW Longer Duration of Temporary Disability No Limits on TTD Benefits Terminating TTD Benefits may be more difficult than in some states

26 Where do we go from here?? Thoughts? Q & A

27 736 SW Washington St; Suite 2A, Peoria, IL N Knoxville Ave; Suite B, Peoria, IL (309) a.haight@iwirc.biz 482 Wylie Dr, Normal, IL (309) a.haight@iwin-us.biz 27