Adam Haight IWIRC Director, Business Development Presentation adapted from information presented by HFN, Inc. at Heartland Healthcare Coalition meeting May 2012
http://www.iwcc.il.gov/act080811.pdf 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
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, 2011 3
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!! 4
Currently, if you are a PPO operating in the state of Illinois, you need to be registered with the Department of Insurance as a Preferred Provider Program Administrator PPA (Now HC-PPP). There is an annual renewal process with the DOI for every PPA in Illinois. 5
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. 6
Employers will direct injured employees to specific providers, the injured workers can only choose providers in the employers preferred provider programs. Providers can only refer PPP patients to a participating, innetwork facility, specialist, etc. The employer is only responsible for payment to in-network providers and in-network referrals. 7
Employees have two choices of PPP providers. If the employee does not opt out, all of the resulting innetwork PPP referrals must come from the PPP providers. If the employee opts-out, in writing, of the employer s PPP, the opt-out counts as one of the employee s two provider choices. The employee is only entitled to one choice of provider and the resulting referrals from that choice of provider. 8
New PPP requirements The provider network shall include an adequate number of occupational and nonoccupational providers. The provider network shall include an adequate number and type of physicians or other providers to treat common injuries experienced by injured workers in the geographic area where the employees reside. Medical treatment for injuries shall be readily available at reasonable times to all employees. To the extent feasible, all medical treatment for injuries shall be readily accessible to all employees. Physician compensation shall not be structured in order to achieve the goal of inappropriately reducing, delaying, or denying medical treatment or restricting access to medical treatment. A program shall establish terms and conditions that must be met by noninstitutional providers wishing to enter into an agreement with the program. These terms and conditions may not discriminate unreasonably against or among noninstitutional providers. 9
New PPP Requirements continued If the administrator of a preferred provider program uses economic evaluation for utilization review, peer review, incentive and penalty programs, and in provider retention and termination decisions, the administrator must file with the Director of Insurance a description of any policies and procedures related to economic evaluation utilized by the program. The economic evaluation cannot inappropriately reduce, delay or deny medical treatment, or to restrict access to medical treatment. Evaluation of providers based upon objective medical quality and patient outcome measurements, appropriate use of best clinical practices and evidence based medicine, and use of health information technology shall be permitted. Treatment by a specialist who is not a member of the preferred provider network shall be permitted on a case-by-case basis if the PPP does not contain a physician who can provide the approved treatment, and if the employee has complied with any pre-authorization requirements of the preferred provider network. 10
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. 11
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. 12
29 Current fee schedule Regions: Regions based on the first 3 digits of the providers service location zip code Effective 1/1/2012 13
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 14
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 15
On July 16, 2014, the Illinois Workers' Compensation Commission (IWCC) voted unanimously to raise reimbursement rates for non-surgical 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. https://www.isms.org/news_and_publications/publications/physician_advocate/2014/0718/breaking_ne ws ISMS_Successful_in_Obtaining_Increased_Reimbursement_for_Illinois_Workers_Comp/ 16
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 17
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, 2011. 18
UR provider must be available in Illinois or by remote electronic means for deposition testimony. An admissible UR shall be considered by the Commission, along with all other evidence, and must be addressed along with other evidence in determining reasonableness and necessity of medical treatment. 19
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 20
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.
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. 22
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 23
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? 24
736 SW Washington St; Suite 2A, Peoria, IL 61602 7725 N Knoxville Ave; Suite B, Peoria, IL 61614 (309) 497-0300 www.iwirc.biz a.haight@iwirc.biz 482 Wylie Dr, Normal, IL 61761 (309) 621-4288 www.iwin-us.biz a.haight@iwin-us.biz 25
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