3-31-10
March 29, 2010 CMS issued a Revised Quick Reference Guide for MMSEA Section 111 Registration (updated Oct. 7, 20131) For Responsible Reporting Entities. But note that CMS cautions everyone that you must read the full updated User Guide.
Q: Why does Medicare supply a 43 page "User Guide" to mandatory claim reporting?
Answer: because the full updated User Guide to Mandatory Reporting (Ver 4.0) updated (Oct. 7, 2013) takes up 463 pages broken down into .pdf sub-parts on the CMS website.
It is anticipated that yet even more changes will be forthcoming but for the most part, most of the gross outline of the claim reporting process, the required data elements and the main provisions have taken shape. There have been substantial changes in this updated User Guide edition in response to industry concerns most notably in regard to who is considered to be a reporting entity (RRE) and in dealing with companies that have a deductible in their workers comp policy.
More CMS Town Hall tele conferences are scheduled for later this year up through June 30,2010 to address even more questions and more industry concerns. Because this changing area of law and the actual requirements are still unfolding, either check with an experienced Illinois workers compensation attorney with questions on where to look for answers or hire a specialized consultant in Medicare Secondary Payor requirements that can closely monitor this specialized area for precise reporting compliance.
If you have reporting responsibilities at your company, you should continue to monitor the CMS page on MMSEA very closely for any new developments and monitor the CMS page for Liability Insurance and Workers' Compensation Reporting for the most up to date information.
Chicago Workers Comp Attorneys -- 3-31-10
Showing posts with label Chicago workers comp attorney. Show all posts
Showing posts with label Chicago workers comp attorney. Show all posts
3/03/2010
Illinois Medical Fee Schedule FAQ and Guidelines 2010
3-3-10
The Illinois Workers Compensation Medical Fee Schedule has been supplemented with answers to FAQs generated from recent fee schedule seminars around the state. As a result of common questions posed by the medical community and workers compensation payers, the Commission issued updated Medical Fee Schedule Instructions and Guidelines ( 1/25/10) for treatment occurring after 2/1/09 and they issued a new list of common Medical Fee Schedule FAQs (1/25/10) that were generated directly out of the seminars.
Naturally, the fee schedule generated a lot of interest from hospitals, treating doctors and the health care providers from the community at large. I share the above links for obtaining updated information that may help workers compensation health care professionals in answering some of their more common questions.
If your representatives were unable to attend the official medical fee schedule seminars, the Medical Fee Schedule Power Point presentation can be found here.
Many answers to medical bill questions were already posted on the Illinois Workers Compensation Commission web site found at “Frequently Asked Medical Questions” . Whenever providers or payers have a medical questions, they are encouraged to check this page first.
These detailed billing questions are often outside the normal knowledge of Illinois workers compensation attorneys as they often relate to very specific billing and payment issues. For example, the updates address correct billing modifiers for bilateral procedures. Not your usual type stuff. While our Chicago workers comp attorneys may not know the answer, we often know where to look or who to ask. As yet another uncommon example, the MS-DRG crosswalk is available online here but the Illinois Workers Comp Fee Schedule incorporates the new MS-DRG hospital inpatient codes for treatment after 6/30/09.
We were just recently asked by a physician at what point can they start charging statutory interest at 1% per month on the unpaid balance of their bills?
That answer is contained in Question # 61 in the updated FAQs. Answer: The medical providers can start charging interest on unpaid amounts after 60 days from the date that the workers compensation payer receives "substantially all of the information necessary to adjudicate the bill".
The exact data elements are not specified in the fee schedule but a workers compensation carrier can certainly argue that interest does not apply if customary billing information is missing. All normal relevant information should be completely filled out on the standardized bill.
The Commission acknowledges that the medical fee schedule guidelines and FAQ cannot address all of the possible questions that might arise in practice but they hope that the parties will continue to use common coding procedures and follow common reimbursement practices to fill in any of the blanks that are not explicitly specified in the guidelines or instructions. You can email your remaining fee schedule questions to feeschdquestions.wcc@illinois.gov
If a dispute continues to exist after reviewing all of the answers provided, the only way for a medical provider to get an official ruling from the Commission is for the employee's attorney or for the employer's attorney to take the issue to trial before an Arbitrator. That arbitration decision can then be subject to an appeal for further review by a panel of the Commissioners who will decide disputed cases for the official ruling of the Commission.
We hope the above links will provide helpful answers our doctors, medical providers and payers while the industry continues to adapt to the new fee schedule changes, requirements and procedures.
Chicago Workers Compensation Attorneys -- 03-02-10
The Illinois Workers Compensation Medical Fee Schedule has been supplemented with answers to FAQs generated from recent fee schedule seminars around the state. As a result of common questions posed by the medical community and workers compensation payers, the Commission issued updated Medical Fee Schedule Instructions and Guidelines ( 1/25/10) for treatment occurring after 2/1/09 and they issued a new list of common Medical Fee Schedule FAQs (1/25/10) that were generated directly out of the seminars.
Naturally, the fee schedule generated a lot of interest from hospitals, treating doctors and the health care providers from the community at large. I share the above links for obtaining updated information that may help workers compensation health care professionals in answering some of their more common questions.
If your representatives were unable to attend the official medical fee schedule seminars, the Medical Fee Schedule Power Point presentation can be found here.
Many answers to medical bill questions were already posted on the Illinois Workers Compensation Commission web site found at “Frequently Asked Medical Questions” . Whenever providers or payers have a medical questions, they are encouraged to check this page first.
These detailed billing questions are often outside the normal knowledge of Illinois workers compensation attorneys as they often relate to very specific billing and payment issues. For example, the updates address correct billing modifiers for bilateral procedures. Not your usual type stuff. While our Chicago workers comp attorneys may not know the answer, we often know where to look or who to ask. As yet another uncommon example, the MS-DRG crosswalk is available online here but the Illinois Workers Comp Fee Schedule incorporates the new MS-DRG hospital inpatient codes for treatment after 6/30/09.
We were just recently asked by a physician at what point can they start charging statutory interest at 1% per month on the unpaid balance of their bills?
That answer is contained in Question # 61 in the updated FAQs. Answer: The medical providers can start charging interest on unpaid amounts after 60 days from the date that the workers compensation payer receives "substantially all of the information necessary to adjudicate the bill".
The exact data elements are not specified in the fee schedule but a workers compensation carrier can certainly argue that interest does not apply if customary billing information is missing. All normal relevant information should be completely filled out on the standardized bill.
The Commission acknowledges that the medical fee schedule guidelines and FAQ cannot address all of the possible questions that might arise in practice but they hope that the parties will continue to use common coding procedures and follow common reimbursement practices to fill in any of the blanks that are not explicitly specified in the guidelines or instructions. You can email your remaining fee schedule questions to feeschdquestions.wcc@illinois.gov
If a dispute continues to exist after reviewing all of the answers provided, the only way for a medical provider to get an official ruling from the Commission is for the employee's attorney or for the employer's attorney to take the issue to trial before an Arbitrator. That arbitration decision can then be subject to an appeal for further review by a panel of the Commissioners who will decide disputed cases for the official ruling of the Commission.
We hope the above links will provide helpful answers our doctors, medical providers and payers while the industry continues to adapt to the new fee schedule changes, requirements and procedures.
Chicago Workers Compensation Attorneys -- 03-02-10
2/19/2010
Mandatory Claim Reporting Date extended to Jan 1, 2011
2-19-10
CMS MIR update alert advises workers' comp and liability RREs that the compliance date for claim reporting is now extended from 4-1-10 until 1-1-11, effective immediately.
- All RREs should now be registered with the COBC, and either in or preparing for file testing. Data testing may continue during 2010, as needed.
- All data exchange testing will be completed by December 31, 2010. RREs that have completed file data exchange testing in place are encouraged to proceed to claim reporting data exchange status.
Chicago Workers Compensation Attorney -- 2-19-10
2/07/2010
Back Due Child Support Ordered Paid out of Workers Comp Settlement
2-07-2010
Section 21 of the Illinois Workers Compensation Act (820 ILCS 305/21 (West 2008)) prohibits all liens on Illinois workers compensation arbitration awards or settlements. This section specifically provides in pertinent part:
Under the law, very few liens are allowed on Illinois workers compensation settlements or awards. There are exceptions of course for Public Aid liens and Medicare’s lien for past related payments but generally the purpose of prohibiting liens in Illinois workers compensation is to protect the injured worker from outstanding claims to ensure that the family has sufficient money to support themselves. However, at least one case now finds that Illinois workers compensation settlements are not immune from claims for past due child support.
In a recent case of Illinois Dept. of Healthcare and Family Services v. Bartholomew (4th Dist. 12/8/09) an unmarried father was already under a wage garnishment order against his paycheck for $428 / month for child support and $85 per month for back due child support. In a further administrative order, he was prohibited from "dissipating" his workers compensation settlement of $175,000. The father agreed that the mother should receive 20% of the workers comp settlement money to pay for his current child support obligations but he contested the lien of about $9,000 claimed in back due child support and interest.
This case confirms that the Withholding Act, 750 ILCS 28/15 paragraph (d), considers “income” to mean any source of periodic payment, including workers compensation payments or settlements. Further, Section 20 (c) (3) specifically allows for withholding of “income” for past due child support.
If the workers compensation settlement is for payment for the loss of a hand, foot, leg or other injury, that money may not be considered as “income” for other purposes since it is not "earned income" but really compensation for the loss or partial loss of the worker's body parts. But here, the Illinois General Assembly and our legislators have established that it is our public policy to withhold money from statutorily defined "income" to ensure that all support judgments are enforced by all available means.
Chicago Workers Compensation Attorneys -- 02-07-10
Section 21 of the Illinois Workers Compensation Act (820 ILCS 305/21 (West 2008)) prohibits all liens on Illinois workers compensation arbitration awards or settlements. This section specifically provides in pertinent part:
“No payment, claim, award or decision under this Act shall be assignable or subject to any lien, attachment or garnishment, or be held liable in any way for any lien, , penalty or damages."
Under the law, very few liens are allowed on Illinois workers compensation settlements or awards. There are exceptions of course for Public Aid liens and Medicare’s lien for past related payments but generally the purpose of prohibiting liens in Illinois workers compensation is to protect the injured worker from outstanding claims to ensure that the family has sufficient money to support themselves. However, at least one case now finds that Illinois workers compensation settlements are not immune from claims for past due child support.
In a recent case of Illinois Dept. of Healthcare and Family Services v. Bartholomew (4th Dist. 12/8/09) an unmarried father was already under a wage garnishment order against his paycheck for $428 / month for child support and $85 per month for back due child support. In a further administrative order, he was prohibited from "dissipating" his workers compensation settlement of $175,000. The father agreed that the mother should receive 20% of the workers comp settlement money to pay for his current child support obligations but he contested the lien of about $9,000 claimed in back due child support and interest.
This case confirms that the Withholding Act, 750 ILCS 28/15 paragraph (d), considers “income” to mean any source of periodic payment, including workers compensation payments or settlements. Further, Section 20 (c) (3) specifically allows for withholding of “income” for past due child support.
If the workers compensation settlement is for payment for the loss of a hand, foot, leg or other injury, that money may not be considered as “income” for other purposes since it is not "earned income" but really compensation for the loss or partial loss of the worker's body parts. But here, the Illinois General Assembly and our legislators have established that it is our public policy to withhold money from statutorily defined "income" to ensure that all support judgments are enforced by all available means.
Chicago Workers Compensation Attorneys -- 02-07-10
7/06/2009
2008 Annual Report Illinois Workers Compensation Commission
7-06-09
On June 30, 2009, the Commission released its Annual Report of Operations for 2008. Highlights indicate that total claims of 57,515 were up slightly 1.5% from previous year totals of 56,685 including both filed claims and pro se settlements. Total claims were down approximately 8% from FY2004.
The Commission operates the state court system for workers' compensation cases. In Fiscal Year 2008, the Commission's operating expenditures were $18.6 million. The Commission's end of year headcount was 162 employees, plus the chairman, nine commissioners, and six Self-Insurance employees who are counted separately, for a total of 178 people. Illinois provides 33 Arbitrators statewide for hearings, settlement approvals and pretrial in approximately 30 hearing locations throughout the state.
The Insurance Compliance unit collected $1.8 million in fines in FY2008 from 66 uninsured employers with 900 workers that were found to be operating without workers’ compensation insurance. If the Commission finds an employer knowingly and willfully failed to obtain insurance coverage, they can be fined up to $500 for every day of noncompliance, with a minimum fine of $10,000. Corporate officers may be held personally liable if the company fails to pay the fine. Under the new compliance laws which took effect July 20, 2005, an employer may also face criminal charges and/or a work-stop order for failing to obtain workers' compensation insurance coverage.
Each year roughly 250,000 work accidents occur in Illinois but only claims involving 3 days or more lost time from work are reportable to the Commission. Approximately 80,000 injuries are reported by employers each year involving 3 days or more lost time. Out of all reportable injuries, approximately 60,000 formal new claims are filed each year by either a formal Application for Benefits or as an original settlement.
In an original settlement, the worker generally does not have an attorney 95% of the time and settles direct with the employer or the insurance carrier. In the year 2008, the annual report reflects original or “pro se" settlements were filed in 9,322 cases representing 16% of all claims. Overall, an injured worker hired an attorney 84% of the time with a formal filed Application for Benefits.
Not surprisingly, Chicago and the collar counties with hub cities within an hour or so from Chicago account for approximately 60% of all Illinois work injury claims. Also not surprisingly, back and neck claims accounted for the largest sector of reported injuries totaling 20% of all injuries in 2008.
Thanks to the addition of a third panel of Commissioners deciding cases at the Review level, in 2008 the formal written decisions from the Commission on appeal from an Arbitration Decision increased by 13% from 2007. A total of 1,195 formal Review Decisions were entered in FY2008 representing 2% of all claim closures. Dismissals accounted for an alarming 9% of cases disposed of while settlements represented 86% of all case closures.
Interestingly, when an injured worker filed an appeal to the Review level before the Commissioners, benefits were increased only 15% of the time. In appeals by the worker, benefits were actually reversed or decreased in 13% of the cases. The great majority of appeals by the worker resulted in no change of the Arbitration Decision in 72% of decisions in appeals filed by the employee.
In employer appeals to the Review stage, benefits were affirmed almost 66% of the time. However, the employer was successful in obtaining a reduction or a decrease in benefits awarded from the Arbitration Decision in 21% of the appeals filed by an employer. Outright reversals were obtained in only 6% of the Review Decisions filed and benefits were actually increased in 6% of the decisions appealed from.
The average time that a case takes from filing an Application for Benefits through the final formal Decision on Review is approximately 4.2 years. That number is deceptively high because in most cases the attorneys and arbitrators are forced to wait until medical care has concluded before an assessment of the permanent nature of the injury can be made or while waiting on final medical restrictions and assessing a return to work status.
The actual appeal times on Review decreased during 2008 to 16 months or 1.33 years from the date of the Arbitration Decision. This represents a significant improvement in delay times on Review. In 19(b) Emergency Petitions for Benefits, the wait time for a Review Decision was under one year at 11 months.
Most litigated cases at the Illinois Commission are settled by and between the attorneys. While total claims disposed of in 2008 totaled 59,533 between settlements, decisions and dismissals, actual formal Arbitration Decisions were issued in only 3,594 cases representing a ratio of 6% of total claim dispositions.
In comparison, the average time it takes for settlement from date of application for benefits until the date of settlement approval was 1.9 years.
The take away message for most may be that the Commission works best in the vast majority of claims by resolving disputes and contested cases through compromise settlement. Parties may be best served by representation with an experienced Illinois workers compensation attorney to arrive at an early compromise settlement rather than face the uncertainties and delays of trial and appeal.
It should be noted that Arbitrators in Illinois perform a significant crucial key function in supplying sound pretrial recommendations to assist attorneys in resolving disputed areas of disagreement in contested cases.
Formal Decisions of the Arbitrator were appealed in only 48% of cases that went to trial and decision so the informal pretrial recommendations by the Arbitrator weigh very strongly with the parties. After all, it's not nice to ignore the pretrial recommendations of the person most crucial to deciding the disputed issues of the case.
Contact an Illinois workers compensation attorney for assistance at (312) 541-0049 or email our office at info@Workcomp-Chicago.com.
Chicago Workers Compensation Attorney -- 7-06-09
On June 30, 2009, the Commission released its Annual Report of Operations for 2008. Highlights indicate that total claims of 57,515 were up slightly 1.5% from previous year totals of 56,685 including both filed claims and pro se settlements. Total claims were down approximately 8% from FY2004.
The Commission operates the state court system for workers' compensation cases. In Fiscal Year 2008, the Commission's operating expenditures were $18.6 million. The Commission's end of year headcount was 162 employees, plus the chairman, nine commissioners, and six Self-Insurance employees who are counted separately, for a total of 178 people. Illinois provides 33 Arbitrators statewide for hearings, settlement approvals and pretrial in approximately 30 hearing locations throughout the state.
The Insurance Compliance unit collected $1.8 million in fines in FY2008 from 66 uninsured employers with 900 workers that were found to be operating without workers’ compensation insurance. If the Commission finds an employer knowingly and willfully failed to obtain insurance coverage, they can be fined up to $500 for every day of noncompliance, with a minimum fine of $10,000. Corporate officers may be held personally liable if the company fails to pay the fine. Under the new compliance laws which took effect July 20, 2005, an employer may also face criminal charges and/or a work-stop order for failing to obtain workers' compensation insurance coverage.
Each year roughly 250,000 work accidents occur in Illinois but only claims involving 3 days or more lost time from work are reportable to the Commission. Approximately 80,000 injuries are reported by employers each year involving 3 days or more lost time. Out of all reportable injuries, approximately 60,000 formal new claims are filed each year by either a formal Application for Benefits or as an original settlement.
In an original settlement, the worker generally does not have an attorney 95% of the time and settles direct with the employer or the insurance carrier. In the year 2008, the annual report reflects original or “pro se" settlements were filed in 9,322 cases representing 16% of all claims. Overall, an injured worker hired an attorney 84% of the time with a formal filed Application for Benefits.
Not surprisingly, Chicago and the collar counties with hub cities within an hour or so from Chicago account for approximately 60% of all Illinois work injury claims. Also not surprisingly, back and neck claims accounted for the largest sector of reported injuries totaling 20% of all injuries in 2008.
Thanks to the addition of a third panel of Commissioners deciding cases at the Review level, in 2008 the formal written decisions from the Commission on appeal from an Arbitration Decision increased by 13% from 2007. A total of 1,195 formal Review Decisions were entered in FY2008 representing 2% of all claim closures. Dismissals accounted for an alarming 9% of cases disposed of while settlements represented 86% of all case closures.
Interestingly, when an injured worker filed an appeal to the Review level before the Commissioners, benefits were increased only 15% of the time. In appeals by the worker, benefits were actually reversed or decreased in 13% of the cases. The great majority of appeals by the worker resulted in no change of the Arbitration Decision in 72% of decisions in appeals filed by the employee.
In employer appeals to the Review stage, benefits were affirmed almost 66% of the time. However, the employer was successful in obtaining a reduction or a decrease in benefits awarded from the Arbitration Decision in 21% of the appeals filed by an employer. Outright reversals were obtained in only 6% of the Review Decisions filed and benefits were actually increased in 6% of the decisions appealed from.
The average time that a case takes from filing an Application for Benefits through the final formal Decision on Review is approximately 4.2 years. That number is deceptively high because in most cases the attorneys and arbitrators are forced to wait until medical care has concluded before an assessment of the permanent nature of the injury can be made or while waiting on final medical restrictions and assessing a return to work status.
The actual appeal times on Review decreased during 2008 to 16 months or 1.33 years from the date of the Arbitration Decision. This represents a significant improvement in delay times on Review. In 19(b) Emergency Petitions for Benefits, the wait time for a Review Decision was under one year at 11 months.
Most litigated cases at the Illinois Commission are settled by and between the attorneys. While total claims disposed of in 2008 totaled 59,533 between settlements, decisions and dismissals, actual formal Arbitration Decisions were issued in only 3,594 cases representing a ratio of 6% of total claim dispositions.
In comparison, the average time it takes for settlement from date of application for benefits until the date of settlement approval was 1.9 years.
The take away message for most may be that the Commission works best in the vast majority of claims by resolving disputes and contested cases through compromise settlement. Parties may be best served by representation with an experienced Illinois workers compensation attorney to arrive at an early compromise settlement rather than face the uncertainties and delays of trial and appeal.
It should be noted that Arbitrators in Illinois perform a significant crucial key function in supplying sound pretrial recommendations to assist attorneys in resolving disputed areas of disagreement in contested cases.
Formal Decisions of the Arbitrator were appealed in only 48% of cases that went to trial and decision so the informal pretrial recommendations by the Arbitrator weigh very strongly with the parties. After all, it's not nice to ignore the pretrial recommendations of the person most crucial to deciding the disputed issues of the case.
Contact an Illinois workers compensation attorney for assistance at (312) 541-0049 or email our office at info@Workcomp-Chicago.com.
Chicago Workers Compensation Attorney -- 7-06-09
6/20/2009
Settlements: Medicare Set Aside Future Drug Costs and Uniform Pricing
6-20-09
Employers may soon see a spike in future drug costs for settlements going through the MSA approval process after June 1, 2009. Medicare will begin independent pricing of future drug costs in Workers Compensation Medicare Set Aside proposals as of June 1, 2009 using Average Wholesale Price (AWP) for drugs based on prices listed in the RED BOOK (r) Drug References.
CMS will no longer recognize other pricing methods using workers compensation contractual discounts for prescription drugs in Medicare Set Aside proposals. What does this mean?? Carriers and employers will be required to fund future drug costs based on the average wholesale price of drugs in use before any contractual discounts, before any WC state fee schedule discounts or before any future shift from brand names to generics. MSA submissions can no longer take advantage of pricing in the "Doughnut hole" into MSA proposals by excluding funds for Medicare Part D prescription deductibles.
The new pricing will assume a lifetime supply of drugs in use at the time of the MSA proposal. CMS will also look to the past 2 years of drugs used and to the expectations for future drug use based on the treating doctor's recommendations.
This recent change adopting uniform pricing is designed to eliminate some of the past abuses in under pricing MSA drug proposals such as "Doughnut hole" pricing and utilization review assumptions of tapering use of narcotics which were not supported by the treating physician's records.
The upshot for most employers is that future drug allowances in a MSA proposals may cost more than if those medical rights had remained open under workers compensation. Carriers may be better off leaving the prescription drug rights open under a settlement and paying for the future drugs using a qualified assignment and purchasing an annuity. That option would allow the carrier or employer to continue to use discounted pricing or use applicable state fee schedules and also let an employer be the residual beneficiary on the annuity policy (should the worker die early) and stand to receive a return of some portion of the money rather than fully funding lifetime drugs at average wholesale prices to satisfy Medicare MSA pricing requirements.
MEDVAL compared the increase in costs from their normal prescription pricing methods to the new average wholesale pricing (AWP) and came up with an astonishing $1.4MM difference on the first 17 cases reviewed. If that jump in pricing is reflective of expected average MSA cost increases under the new AWP pricing requirements, it would truly be a bitter pill to swallow for most employers and most workers comp carriers.
Contact our Chicago workers comp attorneys for questions on Illinois workers compensation settlements and MSA requirements.
(8-23-09) Update: PMSI records significant increase in MSA allocations under new prescription drug guidelines
Chicago workers compensation Attorney -- 6-20-09
Employers may soon see a spike in future drug costs for settlements going through the MSA approval process after June 1, 2009. Medicare will begin independent pricing of future drug costs in Workers Compensation Medicare Set Aside proposals as of June 1, 2009 using Average Wholesale Price (AWP) for drugs based on prices listed in the RED BOOK (r) Drug References.
CMS will no longer recognize other pricing methods using workers compensation contractual discounts for prescription drugs in Medicare Set Aside proposals. What does this mean?? Carriers and employers will be required to fund future drug costs based on the average wholesale price of drugs in use before any contractual discounts, before any WC state fee schedule discounts or before any future shift from brand names to generics. MSA submissions can no longer take advantage of pricing in the "Doughnut hole" into MSA proposals by excluding funds for Medicare Part D prescription deductibles.
The new pricing will assume a lifetime supply of drugs in use at the time of the MSA proposal. CMS will also look to the past 2 years of drugs used and to the expectations for future drug use based on the treating doctor's recommendations.
This recent change adopting uniform pricing is designed to eliminate some of the past abuses in under pricing MSA drug proposals such as "Doughnut hole" pricing and utilization review assumptions of tapering use of narcotics which were not supported by the treating physician's records.
The upshot for most employers is that future drug allowances in a MSA proposals may cost more than if those medical rights had remained open under workers compensation. Carriers may be better off leaving the prescription drug rights open under a settlement and paying for the future drugs using a qualified assignment and purchasing an annuity. That option would allow the carrier or employer to continue to use discounted pricing or use applicable state fee schedules and also let an employer be the residual beneficiary on the annuity policy (should the worker die early) and stand to receive a return of some portion of the money rather than fully funding lifetime drugs at average wholesale prices to satisfy Medicare MSA pricing requirements.
MEDVAL compared the increase in costs from their normal prescription pricing methods to the new average wholesale pricing (AWP) and came up with an astonishing $1.4MM difference on the first 17 cases reviewed. If that jump in pricing is reflective of expected average MSA cost increases under the new AWP pricing requirements, it would truly be a bitter pill to swallow for most employers and most workers comp carriers.
Contact our Chicago workers comp attorneys for questions on Illinois workers compensation settlements and MSA requirements.
(8-23-09) Update: PMSI records significant increase in MSA allocations under new prescription drug guidelines
Chicago workers compensation Attorney -- 6-20-09
5/24/2009
More than Totally and Permanently Disabled from Work Injury in Illinois
5-24-09
Is that possible to receive more than lifetime total disability benefits in Illinois from a single accident? Answer: Yes -- it is possible, but it won’t happen very often.
In Beelman Trucking, (May 21, 2009, Ill. Supreme Ct.) an injured worker received lifetime total disability benefits for the complete paralysis of both legs and he also received an award for the amputation or loss of use of both arms. In Beelman, the employer argued that a worker cannot be more than totally and permanently disabled. The employer argued that the Illinois Workers Compensation Act puts a cap on the benefits available at lifetime permanent total disability benefits. (A lifetime award would normally be at 2/3 of his regular pay for life) The employer argued that a worker cannot possibly be more than totally and permanently disabled in a single work accident.
14 years after a tragic truck accident, a truck driver, Jack Carson, was allowed by the Illinois Supreme Court to keep an award for the loss of both his arms as well as a lifetime pension for paralysis of both his legs.
There is no dispute that an injured worker in Illinois can receive lifetime disability benefits for the loss of 2 arms, 2 hands, 2 legs, 2 feet, 2 eyes or any combination thereof under Section 18(e)(18). The question was whether Carson could keep an additional award of 235 weeks for paralysis of his left arm and an extra 300 weeks compensation for amputation of his right arm on top of the lifetime benefits already awarded.
Illinois essentially recognizes 3 types of permanent and total disability pensions. Lifetime disability benefits are available for those (1) that are “obviously unemployable” because they are wholly and permanently incapable of work, or (2) for someone capable of limited work but they are damaged to the point that there is no stable labor market anymore for a person of like age, training and physical limitations known as “odd-lot” permanent total disability pension and (3) in the case of someone eligible by statute for total disability pension for the amputation or loss of use of 2 arms, 2 hands, 2 legs, 2 feet, 2 eyes or any combination thereof known as a “statutory” permanent total disability.
It is contemplated that someone with a “statutory” total disability pension may eventually even return to work earning some wages but the disability pension is awarded by law for the severe nature of the injuries.
Under the first two disability pensions, a worker cannot receive money by adding up the % of each body part on top of the total disability pension. Under the third type of disability pension, the “statutory” total disability pension involving amputations, it is possible to obtain additional awards for losses on top of the total disability pension.
As a good example, in Freeman United Coal (1984) 99 ILL.2d 487, a coal miner on a “statutory” total disability pension was allowed to receive an additional award for other injuries he received following a second work accident. The difference in Beelman now is that the Supreme Court recognizes an award for injuries on top of the “statutory” disability pension arising out of the same accident rather than requiring a new, second and separate accident at work.
Chicago Workers Compensation Attorney – http://wc-chicago.com -- 5-24-09
Is that possible to receive more than lifetime total disability benefits in Illinois from a single accident? Answer: Yes -- it is possible, but it won’t happen very often.
In Beelman Trucking, (May 21, 2009, Ill. Supreme Ct.) an injured worker received lifetime total disability benefits for the complete paralysis of both legs and he also received an award for the amputation or loss of use of both arms. In Beelman, the employer argued that a worker cannot be more than totally and permanently disabled. The employer argued that the Illinois Workers Compensation Act puts a cap on the benefits available at lifetime permanent total disability benefits. (A lifetime award would normally be at 2/3 of his regular pay for life) The employer argued that a worker cannot possibly be more than totally and permanently disabled in a single work accident.
14 years after a tragic truck accident, a truck driver, Jack Carson, was allowed by the Illinois Supreme Court to keep an award for the loss of both his arms as well as a lifetime pension for paralysis of both his legs.
There is no dispute that an injured worker in Illinois can receive lifetime disability benefits for the loss of 2 arms, 2 hands, 2 legs, 2 feet, 2 eyes or any combination thereof under Section 18(e)(18). The question was whether Carson could keep an additional award of 235 weeks for paralysis of his left arm and an extra 300 weeks compensation for amputation of his right arm on top of the lifetime benefits already awarded.
Illinois essentially recognizes 3 types of permanent and total disability pensions. Lifetime disability benefits are available for those (1) that are “obviously unemployable” because they are wholly and permanently incapable of work, or (2) for someone capable of limited work but they are damaged to the point that there is no stable labor market anymore for a person of like age, training and physical limitations known as “odd-lot” permanent total disability pension and (3) in the case of someone eligible by statute for total disability pension for the amputation or loss of use of 2 arms, 2 hands, 2 legs, 2 feet, 2 eyes or any combination thereof known as a “statutory” permanent total disability.
It is contemplated that someone with a “statutory” total disability pension may eventually even return to work earning some wages but the disability pension is awarded by law for the severe nature of the injuries.
Under the first two disability pensions, a worker cannot receive money by adding up the % of each body part on top of the total disability pension. Under the third type of disability pension, the “statutory” total disability pension involving amputations, it is possible to obtain additional awards for losses on top of the total disability pension.
As a good example, in Freeman United Coal (1984) 99 ILL.2d 487, a coal miner on a “statutory” total disability pension was allowed to receive an additional award for other injuries he received following a second work accident. The difference in Beelman now is that the Supreme Court recognizes an award for injuries on top of the “statutory” disability pension arising out of the same accident rather than requiring a new, second and separate accident at work.
Chicago Workers Compensation Attorney – http://wc-chicago.com -- 5-24-09
2/01/2009
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
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
1/26/2009
Workers’ Comp Lien and Employer’s Uninsured Motorist Coverage
1-26-09
The Illinois Supreme Court recently decided that a workers’ comp lien does not apply to a recovery on an employer’s uninsured motorist policy under the plain meaning of Illinois workers’ compensation lien statute since there was no recovery from a 3rd party. Taylor v. Pekin Ins. Co., 2008 WL 4943700, --- Ill.2d--- (Nov. 2008).
The Illinois workers’ compensation lien statute clearly creates an employer’s right of reimbursement for any workers compensation benefits paid from any 3rd party recovery. By statute, the workers’ compensation lien applies to any award, judgment, or fund received by an injured employee from a 3rd party. 820 ILCS 305/5(b).
It was decided earlier that a workers comp lien does not attach to an employee’s uninsured motorist coverage (Terry v. State Farm Insurance) (2d Dist.1997) as the uninsured motorist recovery is a contract recovery by the claimant against his or her own insurer and not a recovery against a responsible 3rd party.
By way of background in this case, Taylor filed a workers’ compensation claim for a car accident with an uninsured driver. Plaintiff received $162,588.33 in workers’ compensation benefits. Plaintiff then filed a claim for injuries under the employer’s uninsured motorist policy for the employer’s auto policy issued by Pekin Insurance.
At arbitration on the uninsured motorist claim, Taylor was awarded $250,000. The uninsured motorist policy contained a setoff clause for all sums paid under workers’ compensation so Pekin delivered a check to the plaintiff for $87,411.67 representing the $250,000 arbitration award less the setoff for workers comp benefits paid of $162,588.33.
Taylor filed suit claiming he should get 25% attorney’s fees on the $162,588,33 setoff. The Supreme Court said that Taylor’s claim for attorney’s fees misses the point.
The Supreme Court said the plain language of 5(b) clearly states the workers’ comp lien applies where proceedings are instituted against a person, other than the employer, who is liable for damages. Here the claim was not against a 3rd party so the workers comp lien doesn’t apply. If a workers’ comp lien had applied, the employer would have paid 25% attorney’s fees on any lien reimbursement in order to prevent an unjust enrichment to the employer. (Reno v. Maryland Casualty) (1962). Here, there was no workers’ comp lien to apply and there was no reimbursement of lien but rather a setoff in the auto policy.
The Court said that if Taylor had recovered $250,000 from an actual insured 3rd party, he would have received the same net recovery of $87,411.67 after deducting out the employer’s workers’ compensation lien reimbursement. Plaintiff was left in no better or no worse shape than he would have been in if he had recovered from an insured 3rd party.
Workers’ compensation lien questions should be addressed to Illinois workers’ compensation attorneys knowledgeable in workers’ compensation lien reimbursement.
Chicago Workers Compensation Attorney -- http://wc-chicago.com 1-26-09
The Illinois Supreme Court recently decided that a workers’ comp lien does not apply to a recovery on an employer’s uninsured motorist policy under the plain meaning of Illinois workers’ compensation lien statute since there was no recovery from a 3rd party. Taylor v. Pekin Ins. Co., 2008 WL 4943700, --- Ill.2d--- (Nov. 2008).
The Illinois workers’ compensation lien statute clearly creates an employer’s right of reimbursement for any workers compensation benefits paid from any 3rd party recovery. By statute, the workers’ compensation lien applies to any award, judgment, or fund received by an injured employee from a 3rd party. 820 ILCS 305/5(b).
It was decided earlier that a workers comp lien does not attach to an employee’s uninsured motorist coverage (Terry v. State Farm Insurance) (2d Dist.1997) as the uninsured motorist recovery is a contract recovery by the claimant against his or her own insurer and not a recovery against a responsible 3rd party.
By way of background in this case, Taylor filed a workers’ compensation claim for a car accident with an uninsured driver. Plaintiff received $162,588.33 in workers’ compensation benefits. Plaintiff then filed a claim for injuries under the employer’s uninsured motorist policy for the employer’s auto policy issued by Pekin Insurance.
At arbitration on the uninsured motorist claim, Taylor was awarded $250,000. The uninsured motorist policy contained a setoff clause for all sums paid under workers’ compensation so Pekin delivered a check to the plaintiff for $87,411.67 representing the $250,000 arbitration award less the setoff for workers comp benefits paid of $162,588.33.
Taylor filed suit claiming he should get 25% attorney’s fees on the $162,588,33 setoff. The Supreme Court said that Taylor’s claim for attorney’s fees misses the point.
The Supreme Court said the plain language of 5(b) clearly states the workers’ comp lien applies where proceedings are instituted against a person, other than the employer, who is liable for damages. Here the claim was not against a 3rd party so the workers comp lien doesn’t apply. If a workers’ comp lien had applied, the employer would have paid 25% attorney’s fees on any lien reimbursement in order to prevent an unjust enrichment to the employer. (Reno v. Maryland Casualty) (1962). Here, there was no workers’ comp lien to apply and there was no reimbursement of lien but rather a setoff in the auto policy.
The Court said that if Taylor had recovered $250,000 from an actual insured 3rd party, he would have received the same net recovery of $87,411.67 after deducting out the employer’s workers’ compensation lien reimbursement. Plaintiff was left in no better or no worse shape than he would have been in if he had recovered from an insured 3rd party.
Workers’ compensation lien questions should be addressed to Illinois workers’ compensation attorneys knowledgeable in workers’ compensation lien reimbursement.
Chicago Workers Compensation Attorney -- http://wc-chicago.com 1-26-09
5/04/2008
Illinois Construction Workers Employee Classification Act
5-04-08
Effective January 1, 2008, new laws apply to the Construction industry to guarantee the proper classification of Construction Workers. Workers performing services for construction contractors on or after January 1, 2008 are presumed to be employees of the contractor unless they meet the exceptions specified in Section 10 of the Act. If a contractor chooses to misclassify a worker as an independent contractor in violation of the new law, the State of Illinois can assess civil penalties (money, stop work orders) or other remedies. The Department will notify other State agencies such as the Department of Employment Security (unemployment taxes), the Department of Revenue (income taxes for State & Fed) and the Workers’ Compensation Commission (Work comp insurance compliance penalties for no insurance) who are then required to review and check the contractor’s compliance with each of their respective laws. www.state.il.us/agency/idol/laws/Law185.htm
Employee Classification Information Contact #: (217) 782-1710
This new law is certain to give rise to litigation in construction negligence cases and in workers compensation cases for construction site injuries. For a current update on the practical effect of the new law and new cases interpreting the application of this new law, contact our Chicago workers compensation attorneys with any questions or seek out an experienced Illinois attorney specializing in construction litigation.
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