Work Comp Update 2011

Today (September 1, 2011) many parts of the new Workers’ Compensation Act take effect and the ICS wants to ensure you know what changes occur, and what steps you need to take.  Already our office has received phone calls from doctors with stories of employers claiming chiropractic ineligibility.  So first, I would print out an updated Workers’ Compensation Handbook to distribute to your patients and for your own records: http://www.iwcc.il.gov/handbook062811.pdf.

Question #3 on page 20 of the Handbook deals with the choice of physician and is something you should keep readily on hand.  There are a number of changes which are outlined below, but the most infamous one will be the 30% cut to the fee schedule. These fee cuts are across the board for all providers and not chiropractic specific.  The Department of Insurance expects this to result in up to a 10 percent reduction on employer insurance premiums.  Make sure that you update your Workers’ Compensation Fee Schedules to reflect these changes.  The schedule may be found online at: https://iwcc.ingenix.com/IWCC.asp

Advertisement

For accidents on or after 9/1/11, the new Workers’ Comp Act:

• Reduces all current fee schedules by 30% for all treatment performed after 9/1/11.
• Wage differential awards shall be effective only until the petitioner reaches the age of 67 or 5 years after the date of the award becomes final, whichever occurs later.
• To determine Permanent Partial Disability (PPD), a physician submitting an impairment report shall use the most recent AMA guidelines on impairment including objective criteria. The level of disability shall be based on that impairment report, the occupation of the petitioner, the age of the petitioner, the future earning capacity of the petitioner, and evidence of disability in the treating providers’ medical records.
• Precludes compensation if the employee’s intoxication was the proximate cause of his injury or if the employee’s level of intoxication was sufficient to constitute a departure from employment.

Utilization Review (UR) changes for treatment provided on or after 9/1/11:

An employer or its workers’ compensation insurer must send written notice to a health care provider that the employer intends to initiate a review of a workers’ compensation case. Upon receiving written notice, the provider is required to participate in the review.  Both the provider and the employer or insurer must comply with the following guidelines:

• Providers must make reasonable efforts to submit timely and complete reports to support an employer’s request for certification of requested treatment. If the provider fails to make timely and reasonable efforts, the charges may not be compensable or collectible.
• The reviewer must give both the provider and employee written notice of utilization review decisions, citing evidence-based guidelines on which the reviewer has based the decision.
• In a compensable injury case, the only circumstance under which an employer or its agent may deny requested medical treatment is when it has a valid UR report stating that the treatment is excessive or unnecessary.
• If an employer or its agent refuses to pay for services based on a legitimate UR review, the patient (petitioner or claimant) then has the burden of establishing at hearing that variance with the guidelines is warranted in the particular situation. However, unless the Workers’ Compensation Commission makes the determination that the services are excessive or unnecessary, providers may (and should) balance bill the patient for these services. If the Commission makes the determination that the services were excessive or unnecessary, the provider cannot balance bill the patient.
• A medical professional who performs the review must be available for deposition in this state either in person or through telephonic communication. The cost of such depositions shall be paid by the employer/insurer.
• As before, the provider should not balance bill the patient while a case is pending at the Workers’ Compensation Commission.
• The Industrial Commission must consider and discuss UR reports in its decisions regarding the reasonableness and necessity of medical bills or treatment of work injuries.