Bill Text: IL HB4079 | 2023-2024 | 103rd General Assembly | Introduced

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Bill Title: Amends the Workers' Compensation Act. Provides that the Illinois Workers' Compensation Commission shall establish new medical fee schedules applicable on and after September 1, 2024 in accordance with specified criteria. Makes existing medical fee schedules inoperative after August 31, 2024. Provides that a provider may prescribe a one-time 7-day supply unless a prescription for more than 7 days is preauthorized by the employer. Provides for non-hospital fee schedules and hospital fee schedules applicable to different geographic areas of the State. Sets forth a procedure for petitioning the Commission if a maximum fee causes a significant limitation on access to quality health care in either a specific field of health care services or a specific geographic limitation on access to health care. Provides that by September 1, 2023, the Commission, in consultation with the Workers' Compensation Medical Fee Advisory Board, shall adopt by rule an evidence-based drug formulary and any rules necessary for its administration. Provides that prescriptions prescribed for workers' compensation cases shall be limited to the prescription drugs and doses on the closed formulary. Provides that a custom compound medication for longer than the one-time 7-day supply shall be approved for payment only if the compound meets specified standards. Provides for charges for custom compound medications. Effective immediately.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced) 2024-04-05 - Rule 19(a) / Re-referred to Rules Committee [HB4079 Detail]

Download: Illinois-2023-HB4079-Introduced.html

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103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB4079 Introduced , by Rep. Dan Ugaste SYNOPSIS AS INTRODUCED:
820 ILCS 305/8.2
Amends the Workers' Compensation Act. Provides that the Illinois Workers' Compensation Commission shall establish new medical fee schedules applicable on and after September 1, 2024 in accordance with specified criteria. Makes existing medical fee schedules inoperative after August 31, 2024. Provides that a provider may prescribe a one-time 7-day supply unless a prescription for more than 7 days is preauthorized by the employer. Provides for non-hospital fee schedules and hospital fee schedules applicable to different geographic areas of the State. Sets forth a procedure for petitioning the Commission if a maximum fee causes a significant limitation on access to quality health care in either a specific field of health care services or a specific geographic limitation on access to health care. Provides that by September 1, 2023, the Commission, in consultation with the Workers' Compensation Medical Fee Advisory Board, shall adopt by rule an evidence-based drug formulary and any rules necessary for its administration. Provides that prescriptions prescribed for workers' compensation cases shall be limited to the prescription drugs and doses on the closed formulary. Provides that a custom compound medication for longer than the one-time 7-day supply shall be approved for payment only if the compound meets specified standards. Provides for charges for custom compound medications. Effective immediately.
LRB103 32159 SPS 61248 b
A BILL FOR
HB4079 LRB103 32159 SPS 61248 b
AN ACT concerning employment.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Workers' Compensation Act is amended by
changing Section 8.2 as follows:
(820 ILCS 305/8.2)
Sec. 8.2. Fee schedule.
(a) Except as provided for in subsection (c), for
procedures, treatments, or services covered under this Act and
rendered or to be rendered on and after February 1, 2006, the
maximum allowable payment shall be 90% of the 80th percentile
of charges and fees as determined by the Commission utilizing
information provided by employers' and insurers' national
databases, with a minimum of 12,000,000 Illinois line item
charges and fees comprised of health care provider and
hospital charges and fees as of August 1, 2004 but not earlier
than August 1, 2002. These charges and fees are provider
billed amounts and shall not include discounted charges. The
80th percentile is the point on an ordered data set from low to
high such that 80% of the cases are below or equal to that
point and at most 20% are above or equal to that point. The
Commission shall adjust these historical charges and fees as
of August 1, 2004 by the Consumer Price Index-U for the period

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August 1, 2004 through September 30, 2005. The Commission
shall establish fee schedules for procedures, treatments, or
services for hospital inpatient, hospital outpatient,
emergency room and trauma, ambulatory surgical treatment
centers, and professional services. These charges and fees
shall be designated by geozip or any smaller geographic unit.
The data shall in no way identify or tend to identify any
patient, employer, or health care provider. As used in this
Section, "geozip" means a three-digit zip code based on data
similarities, geographical similarities, and frequencies. A
geozip does not cross state boundaries. As used in this
Section, "three-digit zip code" means a geographic area in
which all zip codes have the same first 3 digits. If a geozip
does not have the necessary number of charges and fees to
calculate a valid percentile for a specific procedure,
treatment, or service, the Commission may combine data from
the geozip with up to 4 other geozips that are demographically
and economically similar and exhibit similarities in data and
frequencies until the Commission reaches 9 charges or fees for
that specific procedure, treatment, or service. In cases where
the compiled data contains less than 9 charges or fees for a
procedure, treatment, or service, reimbursement shall occur at
76% of charges and fees as determined by the Commission in a
manner consistent with the provisions of this paragraph.
Providers of out-of-state procedures, treatments, services,
products, or supplies shall be reimbursed at the lesser of

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that state's fee schedule amount or the fee schedule amount
for the region in which the employee resides. If no fee
schedule exists in that state, the provider shall be
reimbursed at the lesser of the actual charge or the fee
schedule amount for the region in which the employee resides.
Not later than September 30 in 2006 and each year thereafter,
the Commission shall automatically increase or decrease the
maximum allowable payment for a procedure, treatment, or
service established and in effect on January 1 of that year by
the percentage change in the Consumer Price Index-U for the 12
month period ending August 31 of that year. The increase or
decrease shall become effective on January 1 of the following
year. As used in this Section, "Consumer Price Index-U" means
the index published by the Bureau of Labor Statistics of the
U.S. Department of Labor, that measures the average change in
prices of all goods and services purchased by all urban
consumers, U.S. city average, all items, 1982-84=100.
(a-1) Notwithstanding the provisions of subsection (a) and
unless otherwise indicated, the following provisions shall
apply to the medical fee schedule starting on September 1,
2011:
(1) The Commission shall establish and maintain fee
schedules for procedures, treatments, products, services,
or supplies for hospital inpatient, hospital outpatient,
emergency room, ambulatory surgical treatment centers,
accredited ambulatory surgical treatment facilities,

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prescriptions filled and dispensed outside of a licensed
pharmacy, dental services, and professional services. This
fee schedule shall be based on the fee schedule amounts
already established by the Commission pursuant to
subsection (a) of this Section. However, starting on
January 1, 2012, these fee schedule amounts shall be
grouped into geographic regions in the following manner:
(A) Four regions for non-hospital fee schedule
amounts shall be utilized:
(i) Cook County;
(ii) DuPage, Kane, Lake, and Will Counties;
(iii) Bond, Calhoun, Clinton, Jersey,
Macoupin, Madison, Monroe, Montgomery, Randolph,
St. Clair, and Washington Counties; and
(iv) All other counties of the State.
(B) Fourteen regions for hospital fee schedule
amounts shall be utilized:
(i) Cook, DuPage, Will, Kane, McHenry, DeKalb,
Kendall, and Grundy Counties;
(ii) Kankakee County;
(iii) Madison, St. Clair, Macoupin, Clinton,
Monroe, Jersey, Bond, and Calhoun Counties;
(iv) Winnebago and Boone Counties;
(v) Peoria, Tazewell, Woodford, Marshall, and
Stark Counties;
(vi) Champaign, Piatt, and Ford Counties;

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(vii) Rock Island, Henry, and Mercer Counties;
(viii) Sangamon and Menard Counties;
(ix) McLean County;
(x) Lake County;
(xi) Macon County;
(xii) Vermilion County;
(xiii) Alexander County; and
(xiv) All other counties of the State.
(2) If a geozip, as defined in subsection (a) of this
Section, overlaps into one or more of the regions set
forth in this Section, then the Commission shall average
or repeat the charges and fees in a geozip in order to
designate charges and fees for each region.
(3) In cases where the compiled data contains less
than 9 charges or fees for a procedure, treatment,
product, supply, or service or where the fee schedule
amount cannot be determined by the non-discounted charge
data, non-Medicare relative values and conversion factors
derived from established fee schedule amounts, coding
crosswalks, or other data as determined by the Commission,
reimbursement shall occur at 76% of charges and fees until
September 1, 2011 and 53.2% of charges and fees thereafter
as determined by the Commission in a manner consistent
with the provisions of this paragraph.
(4) To establish additional fee schedule amounts, the
Commission shall utilize provider non-discounted charge

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data, non-Medicare relative values and conversion factors
derived from established fee schedule amounts, and coding
crosswalks. The Commission may establish additional fee
schedule amounts based on either the charge or cost of the
procedure, treatment, product, supply, or service.
(5) Implants shall be reimbursed at 25% above the net
manufacturer's invoice price less rebates, plus actual
reasonable and customary shipping charges whether or not
the implant charge is submitted by a provider in
conjunction with a bill for all other services associated
with the implant, submitted by a provider on a separate
claim form, submitted by a distributor, or submitted by
the manufacturer of the implant. "Implants" include the
following codes or any substantially similar updated code
as determined by the Commission: 0274
(prosthetics/orthotics); 0275 (pacemaker); 0276 (lens
implant); 0278 (implants); 0540 and 0545 (ambulance); 0624
(investigational devices); and 0636 (drugs requiring
detailed coding). Non-implantable devices or supplies
within these codes shall be reimbursed at 65% of actual
charge, which is the provider's normal rates under its
standard chargemaster. A standard chargemaster is the
provider's list of charges for procedures, treatments,
products, supplies, or services used to bill payers in a
consistent manner.
(6) The Commission shall automatically update all

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codes and associated rules with the version of the codes
and rules valid on January 1 of that year.
(a-1.5) The following provisions apply to procedures,
treatments, services, products, and supplies covered under
this Act and rendered or to be rendered on or after September
1, 2024:
(1) In this Section:
"CPT code" means each Current Procedural
Terminology code, for each geographic region specified
in subsection (b) of this Section, included on the
most recent medical fee schedule established by the
Commission pursuant to this Section.
"DRG code" means each current diagnosis related
group code, for each geographic region specified in
subsection (b) of this Section, included on the most
recent medical fee schedule established by the
Commission pursuant to this Section.
"Geozip" means a three-digit zip code based on
data similarities, geographical similarities, and
frequencies.
"Health care services" means those CPT and DRG
codes for procedures, treatments, products, services,
or supplies for hospital inpatient, hospital
outpatient, emergency room, ambulatory surgical
treatment centers, accredited ambulatory surgical
treatment facilities, and professional services.

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"Health care services" does not include codes
classified as healthcare common procedure coding
systems or dental.
"Medicare maximum fee" means, for each CPT and DRG
code, the current maximum fee for that CPT or DRG code
allowed to be charged by the Centers for Medicare and
Medicaid Services for Medicare patients in that
geographic region. The Medicare maximum fee shall be
the greater of (i) the current maximum fee allowed to
be charged by the Centers for Medicare and Medicaid
Services for Medicare patients in the geographic
region or (ii) the maximum fee charged by the Centers
for Medicare and Medicaid Services for Medicare
patients in the geographic region on January 1, 2024.
"Medicare percentage amount" means, for each CPT
and DRG code, the workers' compensation maximum fee as
a percentage of the Medicare maximum fee.
"Workers' compensation maximum fee" means, for
each CPT and DRG code, the current maximum fee allowed
to be charged under the medical fee schedule
established by the Commission for that CPT or DRG code
in that geographic region.
(2) The Commission shall establish and maintain fee
schedules for procedures, treatments, products, services,
or supplies for hospital inpatient, hospital outpatient,
emergency room, ambulatory surgical treatment centers,

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accredited ambulatory surgical treatment facilities,
prescriptions filled and dispensed outside of a licensed
pharmacy, dental services, and professional services.
These fee schedule amounts shall be grouped into
geographic regions in the following manner:
(A) Four regions for non-hospital fee schedule
amounts shall be utilized:
(i) Cook County;
(ii) DuPage, Kane, Lake, and Will Counties;
(iii) Bond, Calhoun, Clinton, Jersey,
Macoupin, Madison, Monroe, Montgomery, Randolph,
St. Clair, and Washington Counties; and
(iv) all other counties of the State.
(B) Fourteen regions for hospital fee schedule
amounts shall be utilized:
(i) Cook, DuPage, Will, Kane, McHenry, DeKalb,
Kendall, and Grundy Counties;
(ii) Kankakee County;
(iii) Madison, St. Clair, Macoupin, Clinton,
Monroe, Jersey, Bond, and Calhoun Counties;
(iv) Winnebago and Boone Counties;
(v) Peoria, Tazewell, Woodford, Marshall, and
Stark Counties;
(vi) Champaign, Piatt, and Ford Counties;
(vii) Rock Island, Henry, and Mercer Counties;
(viii) Sangamon and Menard Counties;

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(ix) McLean County;
(x) Lake County;
(xi) Macon County;
(xii) Vermilion County;
(xiii) Alexander County; and
(xiv) all other counties of the State.
If a geozip overlaps into one or more of the
regions set forth in this subsection, then the
Commission shall average or repeat the charges and
fees in a geozip in order to designate charges and fees
for each region.
(3) The initial workers' compensation maximum fee for
each CPT and DRG code as of September 1, 2024 shall be
determined as follows:
(A) Within 45 days after the effective date of
this amendatory Act of the 103rd General Assembly, the
Commission shall determine the Medicare percentage
amount for each CPT and DRG code using the most recent
data available.
CPT or DRG codes which have a value, but are not
covered expenses under Medicare, are still compensable
under the medical fee schedule according to the rate
described in subparagraph (B).
(B) Within 30 days after the Commission makes the
determinations required under subparagraph (A), the
Commission shall determine an adjustment to be made to

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the workers' compensation maximum fee for each CPT and
DRG code as follows:
(i) if the Medicare percentage amount for that
CPT or DRG code is equal to or less than 125%, then
the workers' compensation maximum fee for that CPT
or DRG code shall be adjusted so that it equals
125% of the most recent Medicare maximum fee for
that CPT or DRG code;
(ii) if the Medicare percentage amount for
that CPT or DRG code is greater than 125% but less
than 150%, then the workers' compensation maximum
fee for that CPT or DRG code shall not be adjusted;
(iii) if the Medicare percentage amount for
that CPT or DRG code is greater than 150% but less
than or equal to 225%, then the workers'
compensation maximum fee for that CPT or DRG code
shall be adjusted so that it equals the greater of
(I) 150% of the most recent Medicare maximum fee
for that CPT or DRG code or (II) 85% of the most
recent workers' compensation maximum amount for
that CPT or DRG code;
(iv) if the Medicare percentage amount for
that CPT or DRG code is greater than 225% but less
than or equal to 428.57%, then the workers'
compensation maximum fee for that CPT or DRG code
shall be adjusted so that it equals the greater of

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(I) 191.25% of the most recent Medicare maximum
fee for that CPT or DRG code or (II) 70% of the
most recent workers' compensation maximum amount
for that CPT or DRG code; or
(v) if the Medicare percentage amount for that
CPT or DRG code is greater than 428.57%, then the
workers' compensation maximum fee for that CPT or
DRG code shall be adjusted so that it equals 300%
of the most recent Medicare maximum fee for that
CPT or DRG code.
The Commission shall promptly publish on its
website the adjustments determined pursuant to this
subparagraph (B).
(C) The initial workers' compensation maximum fee
for each CPT and DRG code as of September 1, 2024 shall
be equal to the workers' compensation maximum fee for
that code as determined and adjusted pursuant to
subparagraph (B), subject to any further adjustments
under paragraph (5) of this subsection.
(4) The Commission, as of September 1, 2025 and
September 1 of each year thereafter, shall adjust the
workers' compensation maximum fee for each CPT or DRG code
to exactly half of the most recent annual increase in the
Consumer Price Index-U.
(5) A person who believes that the workers'
compensation maximum fee for a CPT or DRG code, as

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otherwise determined pursuant to this subsection, creates
or would create upon implementation a significant
limitation on access to quality health care in either a
specific field of health care services or a specific
geographic limitation on access to health care may
petition the Commission to modify the workers'
compensation maximum fee for that CPT or DRG code so as to
not create that significant limitation.
The petitioner bears the burden of demonstrating, by a
preponderance of the credible evidence, that the workers'
compensation maximum fee that would otherwise apply would
create a significant limitation on access to quality
health care in either a specific field of health care
services or a specific geographic limitation on access to
health care. Petitions shall be made publicly available.
Such credible evidence shall include empirical data
demonstrating a significant limitation on access to
quality health care. Other interested persons may file
comments or responses to a petition within 30 days after
the filing of a petition.
The Commission shall take final action on each
petition within 180 days after filing. The Commission may,
but is not required to, seek the recommendation of the
Medical Fee Advisory Board to assist with this
determination. If the Commission grants the petition, the
Commission shall further increase the workers'

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compensation maximum fee for that CPT or DRG code by the
amount minimally necessary to avoid creating a significant
limitation on access to quality health care in either a
specific field of health care services or a specific
geographic limitation on access to health care. The
increased workers' compensation maximum fee shall take
effect upon entry of the Commission's final action.
(a-2) For procedures, treatments, services, or supplies
covered under this Act and rendered or to be rendered on or
after September 1, 2011, the maximum allowable payment shall
be 70% of the fee schedule amounts, which shall be adjusted
yearly by the Consumer Price Index-U, as described in
subsection (a) of this Section.
(a-2.5) Subsections (a), (a-1), and (a-2) are inoperative
on and after August 31, 2024.
(a-3) Prescriptions filled and dispensed outside of a
licensed pharmacy shall be subject to a fee schedule that
shall not exceed the Average Wholesale Price (AWP) plus a
dispensing fee of $4.18. AWP or its equivalent as registered
by the National Drug Code shall be set forth for that drug on
that date as published in Medi-Span Medispan.
(a-3.5) By September 1, 2023, the Commission, in
consultation with the Workers' Compensation Medical Fee
Advisory Board, shall adopt by rule an evidence-based drug
formulary and any rules necessary for its administration.
Prescriptions prescribed for workers' compensation cases shall

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be limited to the prescription drugs and doses on the closed
formulary.
A request for a prescription that is not on the closed
formulary shall be reviewed under Section 8.7.
(a-4) As used in this Section, "custom compound
medication" means a customized medication prescribed or
ordered by a duly licensed prescriber for a specific patient
that is prepared in a pharmacy by a licensed pharmacist in
response to a licensed prescriber's prescription or order by
combining, mixing, or altering of ingredients, but not
reconstituting, to meet the unique needs of a specific
patient.
(a-5) A custom compound medication for longer than the
one-time 7-day supply described in subsection (a-6) shall be
approved for payment only if the compound meets all of the
following standards:
(1) there is no readily available commercially
manufactured equivalent product;
(2) no other Food and Drug Administration-approved
alternative drug is appropriate for the patient;
(3) the active ingredients of the compound each have a
National Drug Code number, are components of drugs
approved by the Food and Drug Administration, and the
active ingredients in the custom compound medication are
being used for diagnosis or conditions approved use by the
Food and Drug Administration and not being used for

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off-label use;
(4) the drug has not been withdrawn or removed from
the market for safety reasons; and
(5) the prescriber is able to demonstrate to the payer
that the compound medication is clinically appropriate for
the intended use.
(a-6) Custom compound medications shall be charged using
the specific amount of each component drug and its original
manufacturer's National Drug Code number included in the
compound. Charges shall be based on a maximum charge of the
average wholesale price based upon the original manufacturer's
National Drug Code number, as published by Red Book or
Medi-Span and prorated for each component amount used. If the
National Drug Code for the compound ingredient is a repackaged
drug, the maximum allowable fee for the repackaged drug shall
be determined by the National Drug Code and the average
wholesale price of the underlying original manufacturer.
Components without National Drug Code numbers shall not be
charged. A single dispensing fee for a custom compound
medication as determined by the Commission based on the actual
costs of preparing and dispensing the custom compound
medication shall be paid. The dispensing fee for a compound
prescription shall be billed with code WC 700-C. The provider
may prescribe a one-time 7-day supply. Any custom compound
medication prescriptions for more than 7 days shall be
preauthorized by the employer. Under all circumstances, if the

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compound medication meets the requirements in subsection
(a-5), a 7-day supply shall be covered.
(a-7) This Section is subject to the other provisions of
this Act, including, but not limited to, Section 8.7.
(b) Notwithstanding the provisions of subsection (a), if
the Commission finds that there is a significant limitation on
access to quality health care in either a specific field of
health care services or a specific geographic limitation on
access to health care, it may change the Consumer Price
Index-U increase or decrease for that specific field or
specific geographic limitation on access to health care to
address that limitation.
(c) The Commission shall establish by rule a process to
review those medical cases or outliers that involve
extra-ordinary treatment to determine whether to make an
additional adjustment to the maximum payment within a fee
schedule for a procedure, treatment, or service.
(d) When a patient notifies a provider that the treatment,
procedure, or service being sought is for a work-related
illness or injury and furnishes the provider the name and
address of the responsible employer, the provider shall bill
the employer or its designee directly. The employer or its
designee shall make payment for treatment in accordance with
the provisions of this Section directly to the provider,
except that, if a provider has designated a third-party
billing entity to bill on its behalf, payment shall be made

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directly to the billing entity. Providers shall submit bills
and records in accordance with the provisions of this Section.
(1) All payments to providers for treatment provided
pursuant to this Act shall be made within 30 days of
receipt of the bills as long as the bill contains
substantially all the required data elements necessary to
adjudicate the bill.
(2) If the bill does not contain substantially all the
required data elements necessary to adjudicate the bill,
or the claim is denied for any other reason, in whole or in
part, the employer or insurer shall provide written
notification to the provider in the form of an explanation
of benefits explaining the basis for the denial and
describing any additional necessary data elements within
30 days of receipt of the bill. The Commission, with
assistance from the Medical Fee Advisory Board, shall
adopt rules detailing the requirements for the explanation
of benefits required under this subsection.
(3) In the case (i) of nonpayment to a provider within
30 days of receipt of the bill which contained
substantially all of the required data elements necessary
to adjudicate the bill, (ii) of nonpayment to a provider
of a portion of such a bill, or (iii) where the provider
has not been issued an explanation of benefits for a bill,
the bill, or portion of the bill up to the lesser of the
actual charge or the payment level set by the Commission

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in the fee schedule established in this Section, shall
incur interest at a rate of 1% per month payable by the
employer to the provider. Any required interest payments
shall be made by the employer or its insurer to the
provider within 30 days after payment of the bill.
(4) If the employer or its insurer fails to pay
interest within 30 days after payment of the bill as
required pursuant to paragraph (3), the provider may bring
an action in circuit court for the sole purpose of seeking
payment of interest pursuant to paragraph (3) against the
employer or its insurer responsible for insuring the
employer's liability pursuant to item (3) of subsection
(a) of Section 4. The circuit court's jurisdiction shall
be limited to enforcing payment of interest pursuant to
paragraph (3). Interest under paragraph (3) is only
payable to the provider. An employee is not responsible
for the payment of interest under this Section. The right
to interest under paragraph (3) shall not delay, diminish,
restrict, or alter in any way the benefits to which the
employee or his or her dependents are entitled under this
Act.
The changes made to this subsection (d) by this amendatory
Act of the 100th General Assembly apply to procedures,
treatments, and services rendered on and after the effective
date of this amendatory Act of the 100th General Assembly.
(e) Except as provided in subsections (e-5), (e-10), and

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(e-15), a provider shall not hold an employee liable for costs
related to a non-disputed procedure, treatment, or service
rendered in connection with a compensable injury. The
provisions of subsections (e-5), (e-10), (e-15), and (e-20)
shall not apply if an employee provides information to the
provider regarding participation in a group health plan. If
the employee participates in a group health plan, the provider
may submit a claim for services to the group health plan. If
the claim for service is covered by the group health plan, the
employee's responsibility shall be limited to applicable
deductibles, co-payments, or co-insurance. Except as provided
under subsections (e-5), (e-10), (e-15), and (e-20), a
provider shall not bill or otherwise attempt to recover from
the employee the difference between the provider's charge and
the amount paid by the employer or the insurer on a compensable
injury, or for medical services or treatment determined by the
Commission to be excessive or unnecessary.
(e-5) If an employer notifies a provider that the employer
does not consider the illness or injury to be compensable
under this Act, the provider may seek payment of the
provider's actual charges from the employee for any procedure,
treatment, or service rendered. Once an employee informs the
provider that there is an application filed with the
Commission to resolve a dispute over payment of such charges,
the provider shall cease any and all efforts to collect
payment for the services that are the subject of the dispute.

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Any statute of limitations or statute of repose applicable to
the provider's efforts to collect payment from the employee
shall be tolled from the date that the employee files the
application with the Commission until the date that the
provider is permitted to resume collection efforts under the
provisions of this Section.
(e-10) If an employer notifies a provider that the
employer will pay only a portion of a bill for any procedure,
treatment, or service rendered in connection with a
compensable illness or disease, the provider may seek payment
from the employee for the remainder of the amount of the bill
up to the lesser of the actual charge, negotiated rate, if
applicable, or the payment level set by the Commission in the
fee schedule established in this Section. Once an employee
informs the provider that there is an application filed with
the Commission to resolve a dispute over payment of such
charges, the provider shall cease any and all efforts to
collect payment for the services that are the subject of the
dispute. Any statute of limitations or statute of repose
applicable to the provider's efforts to collect payment from
the employee shall be tolled from the date that the employee
files the application with the Commission until the date that
the provider is permitted to resume collection efforts under
the provisions of this Section.
(e-15) When there is a dispute over the compensability of
or amount of payment for a procedure, treatment, or service,

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and a case is pending or proceeding before an Arbitrator or the
Commission, the provider may mail the employee reminders that
the employee will be responsible for payment of any procedure,
treatment or service rendered by the provider. The reminders
must state that they are not bills, to the extent practicable
include itemized information, and state that the employee need
not pay until such time as the provider is permitted to resume
collection efforts under this Section. The reminders shall not
be provided to any credit rating agency. The reminders may
request that the employee furnish the provider with
information about the proceeding under this Act, such as the
file number, names of parties, and status of the case. If an
employee fails to respond to such request for information or
fails to furnish the information requested within 90 days of
the date of the reminder, the provider is entitled to resume
any and all efforts to collect payment from the employee for
the services rendered to the employee and the employee shall
be responsible for payment of any outstanding bills for a
procedure, treatment, or service rendered by a provider.
(e-20) Upon a final award or judgment by an Arbitrator or
the Commission, or a settlement agreed to by the employer and
the employee, a provider may resume any and all efforts to
collect payment from the employee for the services rendered to
the employee and the employee shall be responsible for payment
of any outstanding bills for a procedure, treatment, or
service rendered by a provider as well as the interest awarded

HB4079 - 23 - LRB103 32159 SPS 61248 b
under subsection (d) of this Section. In the case of a
procedure, treatment, or service deemed compensable, the
provider shall not require a payment rate, excluding the
interest provisions under subsection (d), greater than the
lesser of the actual charge or the payment level set by the
Commission in the fee schedule established in this Section.
Payment for services deemed not covered or not compensable
under this Act is the responsibility of the employee unless a
provider and employee have agreed otherwise in writing.
Services not covered or not compensable under this Act are not
subject to the fee schedule in this Section.
(f) Nothing in this Act shall prohibit an employer or
insurer from contracting with a health care provider or group
of health care providers for reimbursement levels for benefits
under this Act different from those provided in this Section.
(g) On or before January 1, 2010 the Commission shall
provide to the Governor and General Assembly a report
regarding the implementation of the medical fee schedule and
the index used for annual adjustment to that schedule as
described in this Section.
(Source: P.A. 100-1117, eff. 11-27-18; 100-1175, eff.
1-11-19.)
Section 99. Effective date. This Act takes effect upon
becoming law.