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

Social Security Disability and Illinois Workers Comp Settlements

2-01-09

Social Security disability and workers comp combined benefits will pay up to 80% of the former monthly income subject to a maximum monthly payment. The general rule is that the combined benefits between Social Security and Workers Compensation cannot exceed 80% of a person’s former monthly income.

Disabled workers can try to maximize the combination of workers compensation benefits and Social Security Disability payments. Workers facing permanent job loss due to injury or total disability should consult a Chicago workers compensation attorney for advice as early as possible.

The workers’ compensation credit against Social Security benefit payments, or the “workers compensation offset” as it is known, is any amount over the 80% combined benefit maximum. Social Security disability benefits are reduced dollar for dollar if the total combined monthly benefits are over 80% of former “average earnings.” The 80% rule is designed to prevent people from making more money staying home on disability than they would have earned by working. Social Security takes a credit for workers compensation payments and sets a maximum cap on the combined benefits.

Social Security defines the former average earnings as a person’s highest monthly earnings either (1) from an average from the highest five years in a row after 1950 or (2) based on a single calendar year of the highest earnings.

This 80% of former monthly income rule effectively caps the maximum amount available from combining both WC and SSD benefits. Social Security disability benefits also have a maximum payment no matter how high the 80% former income figure may be. SSD does not attempt to make sure that an injured worker actually reaches the full 80% of former income level for medium to high wage earners. The low maximum SSD disability payments will usually result in an income loss for disabled wage earners if they are not adequately compensated in workers compensation.

The SSD portion of payments under the 80% combined benefits rule usually changes from when a worker is receiving WC weekly temporary disability payments compared to a different payment amount after the WC case is settled. Workers must ask Social Security for a recalculation of their benefits after the WC case is settled. The SSD monthly benefit can often increase after a settlement.

Stated simply, the monthly SSD benefit and the WC benefit cannot be greater than 80% of the worker’s former income. In practice, if the workers compensation settlement is spread out over the lifetime of the injured worker, it will generally result in a smaller workers' compensation offset. The terms of a WC settlement are extremely important in order to maximize the combined monthly benefits.

Illinois law allows for a single lump sum payment of workers compensation case which can reduce the effects of the Social Security offset. The law allows for a proration or spread of the settlement amount out over the expected lifetime of the worker. Failure to use the proper settlement terms however can result in a complete suspension or termination of SSD benefits up to the entire amount of the settlement.

Chicago Workers Compensation Attorney ----http://wc-chicago.com/ -- 2-01-09