1 (888) 962 5246 Email Us!

Work Comp Reform in Illinois – The Details

Last Updated on Thursday, 03 November 2011 05:11

With the passage of major work comp reform in Illinois, there’s lots of interest in determining exactly what was passed, and more importantly what it means.

First, the bill. It’s not easy to find it, as it is ‘hidden’ on the Illinois state site; when you click on the link for HB 1698 it brings up a bill addressing adoption; I have no idea why, probably due to parliamentary procedure requirements dealing with bill introduction.

The bill you’re looking for is here.

There are several provisions that address key issues.

Tightening awards for carpal tunnel – this had to be in thereA report by the Belleville News-Democrat on a ‘pandemic’ of carpal tunnel claims filed by guards at a downstate prison incited outrage across the state. According to the story, “taxpayers paid almost $10 million to employees at Menard [the prison] for various workers’ compensation injuries. In all, more than 500 claims were filed, and about half are pending.”

Utilization review – while UR has been around for years in IL, it’s been a pretty toothless UR. The new provisions put the onus on the worker to show why their treatment is appropriate if the payer finds it does not meet criteria for medical necessity.

Fee schedule reduction – the biggie. While there’s so much spin around this from providers it’s a wonder Illinois hasn’t disappeared into a vortex, there’s no getting around this – its a major reduction in provider reimbursement. Yes, their fees will still be among the highest in the country, but a thirty percent reduction is meaningful. There’s a bit of confusion about the basis for the fee schedule; currently it is based on 90 percent of Ingenix’ 80th percentile, split up into 29 geographic areas. There’s an annual inflation rate increase pegged to the CPI.

Provider networks – the ‘Preferred Provider Program’ – yes, this brings employer direction to Illinois work comp. Well, sorta. Here are some of the details (there’s lots to digest, so this is going to take some time).

– the State Department of Insurance has to certify Preferred Provider Programs – there’s too much text to quote here – search for “Sec. 8.1a. Preferred provider programs” – relevant section starts on page 88 line 23.

– when an employee reports an injury the employer has to tell him/her of the PPP and the employee’s need to choose a physician from the PPP.

– employees can opt out of the PPP – here’s the relevant text:

“Subsequent to the report of an injury by an employee, the employee may choose in writing at any time to decline the preferred provider program, [emphasis added] in which case that would constitute one of the two choices of medical providers to which the employee is entitled under subsection (a)(2) or (a)(3)”

Essentially this allows the injured worker to choose their initial treating doc, who controls their referrals to specialists, ancillary providers, and facilities. My take on the network direction provision is it is pretty weak, and – realistically – will help with those claimants engaged in doctor shopping. However, payers’ ability to control which physicians and other providers treat their injured worker, while certainly strengthened, is not greatly enhanced.

There’s a lot more to this, and undoubtedly more to be determined through the regulatory process as well. I leave discussion of impairment ratings, disability determination, and other key provisions to those more expert than I.

What does this mean to you?

For employers, and most employees, and certainly taxpayers – this is long awaited and pretty good news. Costs will come down. Doctor shopping, while not fixed, will be more visible and better monitored. Providers will have to show payers and employers they are serious about treating with a focus on return to work.

And premiums, and the burden on Illinois’ taxpayers, will come down too.

Author Info

Claims Eval