New Illinois Workers Comp Medical Fee Schedule for Outpatient Services

02-02-09

New Rules and a new Medical Fee Schedule apply for maximum fees in hospital outpatient and ambulatory surgical centers under Illinois workers' compensation effective Feb. 1, 2009. (See: Illinois Workers Compensation Medical Fee Schedule Instructions and Guidelines for Treatment on or after Feb. 1, 2009)

The Illinois Joint Committee on Administrative Rules (JCAR) approved changes to the Medical Fee Schedule to add maximum payment amounts for Hospital Outpatient and Ambulatory Surgery. The legislative committee adopted the proposed changes on January 13, 2009. The new Out-patient rates are effective February 1, 2009 according to Ms. Susan Piha in a formal Commission announcement.

In-patient charges and Physician reimbursement rates were already in place in the Medical Fee Schedule for all inpatient, trauma and doctor's professional fees for medical care effective February 1, 2006. The new inpatient and professional rates for 2009 have been posted to the medical fee schedule website. The new 2009 fee schedule rates increased by 5.37%, which reflect the annual cost of living adjustments in the Consumer Price Index (U) for all treatment rendered as of January 1, 2009. Where there is no fee schedule amount listed or available for a procedure, the default rate is 76% of the charged amount.

The new Outpatient and Ambulatory Surgery rates were 2 years in the making. Historical charges were analyzed from 2002 to 2004 broken down by the 3 number Geozip (1st three numbers of a zip code) , i.e., 606—for Chicago. Compromises on the rules and fee schedule implementation were reached in long running deliberations between labor, industry and medical representatives of the Medical Fee Advisory Board. Their hard work and endless hours of analyzing data by the Commission staff have finally come to fruition. Illinois now has one of the most comprehensive workers' compensation medical fee schedules in the United States.

The new Outpatient Medical Fee Schedule sets forth the maximum limits for payment for of 1) ambulatory surgical centers 2) hospital outpatient surgery, radiology, pathology, laboratory, physical medicine and rehabilitation services and 3) new rates for free standing specialized rehabilitation hospitals.

Workers' compensation payment rates are based on the medical procedure code, the date of service and the location (or zip code) where the medical care is rendered.

The maximum payment amounts under the fee schedule are set out as 1) the lesser of the Fee Schedule amount or the actual charge or 2) a contractual rate amount governed by a "negotiated" medical provider contract. An existing contract will control over amounts set forth in the new fee schedule. Special 65% of amount charged rules still apply for any add-ons or pass through charges for hardware devices, instrumentation or medical devices.

In progress, Illinois will be converting to the new MS-DRGs scheduled to be adopted no later than June 30,2009 applying the new Medicare severity codes.

Chicago Workers Comp Attorney – http://wc-chicago.com/ 02-02-09