3/31/2010
Medicare Mandatory Reporting Timelines Revised and Quick Reference Guide
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
3/03/2010
Illinois Medical Fee Schedule FAQ and Guidelines 2010
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
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
2/03/2010
Illinois Temporary Disability Awarded After Termination for Cause
2-03-2010
The Illinois Supreme Court recently upset many Illinois defense attorneys and insurance claims professionals in a hotly contested decision ruling that the employer owes temporary disability benefits even after a "firing for cause" where the worker is on light duty restrictions and has not yet medically stabilized or reached MMI.
This case has been the subject of some spirited discussion on the Workers Compensation Forum on LinkedIn with worries that injured employees can now start fights, threaten supervisors or even commit crimes leading to their valid discharge and still be able to collect temporary total disability compensation.
For background, an Illinois construction worker, Jeff Urban, was working light duty following a legitimate heat stroke injury and returned to work on light duty when he was allegedly fired for writing religious graffiti on a store room shelf. (yes, this was the subject of an earlier post; Carpenter fired for Religious Graffiti).
It turns out that an ugly argument had erupted over an overpayment in a light duty check weeks following the graffiti incident. Although the worker had voluntarily reported the payroll error to the payroll department, he was confronted in a heated exchange about cashing and keeping the overpayment. The argument escalated when the worker called the local police to the job site to file charges of harassment against an administrative assistant whereupon he was terminated shortly thereafter.
The employer based the termination on defacement of property for writing the religious graffiti on shelves in a store room. The defacement of property would normally be a valid cause for firing in Illinois, but it came out that the graffiti occurred weeks earlier and other workers that scribbled graffiti were not similarly fired. The firing really only occurred after the heated argument over the overpayment in the light duty check which was in fact a payroll error. All temporary disability benefits were terminated following the argument and the employee's termination.
At trial, an Arbitrator denied temporary benefits after termination. The Commission however, reversed and awarded temporary disability benefits focusing on the fact that the injury had not yet stabilized nor reached MMI. They found that the worker was still temporarily disabled from his regular duty job despite the employer's argument about denying benefits over a termination for cause.
In a case of first impression, the Illinois Appellate Court considered the entitlement of a worker to temporary disability pay, or actually temporary partial disability pay, where the worker was working under light duty restrictions but fired for an unrelated cause. Interstate Scaffolding v. Workers Compensation Commission (Oct. 20, 2008, 3rd Dist App.)
The Appellate Court naturally looked to Professor Larson on Workers Compensation Law (see Larson's Worker's Compensation Law § 84.04D Physical Incapacity -- Employee's Misconduct, at 84-17 (2007).
Under prior Illinois law, the right to ongoing disability after leaving light duty employment had centered on whether the departure from light duty employment was voluntary or volitional on the worker's part or whether departure was involuntary due to the work related injury medical disability.
In reviewing cases from other jurisdictions provided by Larson's, the Interstate Appellate Court noted that some jurisdictions do deny compensation where the disability played no part in the discharge citing Palmer v. Alliance 917 So.2d 510, 514 (L.A. Ct. App.2005) and Calvert v. General Motors, 327 N.W.2d 542.546 (Mich. Ct. App. 1982) holding an employee discharged for "just cause" is not entitled to ongoing disability benefits.
Other jurisdictions however were also noted to uphold the right to collect benefits after a firing while on light duty employment only if the employee could prove that the inability to find other employment was related to the job injury disability itself, citing Cunningham v. Atlantic, 901 A.2d 956 (N.J. Super.Ct. App. Div. 2006) and Marsolek v. Hormel, 438 N.W.2d 922, 924 (Minn.1989) (that a justifiable discharge for misconduct suspends the rights to compensation unless the cause of the employee's inability to find other suitable employment is related to the work injury disability)
The Appellate Court found that there was no evidence that the employer terminated the worker merely to avoid paying disability benefits, but rather that it was the worker's own volitional conduct in defacing company property that was the real cause for discharge. The employee would have continued to receive benefits until medically stabilized but for his own misconduct. Accordingly, a divided Appellate Court found temporary benefits after the termination were properly denied.
You can contrast this decision with other recent Illinois Commission decisions in Wleklinski v Kelly Services (08 IWCC 254, March 2008) where a temporary worker at RR Donnelly suffered a wrist sprain accident on 11/14/06 with immediate notice and immediate medical care. The employer terminated the worker for leaving her machine early and failing to punch out on the day of the accident. The employer refused to pay any temporary disability benefits claiming a valid termination and they failed to provide any suitable light duty work. The arbitrator awarded temporary disability benefits and a total of $7,616.07 in penalties and attorneys fees stating that merely severing the employment relationship was not sufficient to sever the employer's obligation to provide ongoing temporary total benefits for an undisputed accident.
In Sapp v Wal-Mart (06 IWCC 459 , May 2006) a 37 year old cashier had an uncontested low back injury lifting a fan into a shopping cart. She was subsequently terminated for absenteeism while on light duty. The arbitrator denied benefits after the termination but the Commission reversed and awarded temporary benefits. The Commission focused on the test for determining ongoing entitlement to disability benefits following the termination as whether the medical condition had reached Maximum Medical Improvement and not just whether the cashier was capable of working light duty. Accordingly, the Commission awarded temporary disability benefits following the termination.
The Illinois Commission previously decided Alicea v. Sysco (06 IWCC 596, July 2006), wherein a 42 year old working for Sysco Food Services injured his right shoulder in an undisputed accident and underwent surgery for a shoulder dislocation but the employer previously fired him for violation of a safety rule during the accident. The employer then denied benefits entirely during a light duty release to return to work arguing that the safety rule violation termination barred the right to temporary disability benefits altogether. The Arbitrator held and the Commission affirmed that the termination based upon the safety rule violation did not entirely remove the worker from the sphere of employment and they awarded entitlement to temporary disability benefits.
Our Illinois Supreme Court considered the question of an employee's "discharge for cause" as a basis for denying temporary disability benefits. The Court looked to the law found in the Illinois Workers Compensation Act and found no statutory authority to justify denial, suspension, or termination of TTD benefits based upon an employee's discharge by his employer for unrelated causes. Interstate Scaffolding v. Workers Compensation Commission. (1-22-2010, Docket # 107852)The "test" according to the Court is, was and always has been whether the employee "remains temporarily disabled" as a result of the work related injury and "whether the employee is capable of returning to the work force."
They noted that the Illinois Workers Compensation Act supports suspension or termination of disability benefits for (1) refusing reasonable medical treatment, (2) for failing to cooperate with rehabilitation efforts or (3) for refusing work which falls within the treating doctor's restrictions however they concluded that no statutory basis exists in the Act for terminating benefits following an unrelated discharge for cause.
The Illinois Supreme Court was emphatic in stating that Illinois is an employment "at-will" state and an employee may be discharged for any reason or no reason at all, but whether the discharge is for a valid cause or whether the discharge is somehow discriminatory are simply matters foreign to Illinois Workers Compensation. The entitlement to ongoing temporary disability compensation is wholly a separate issue and not dependent upon the propriety of the discharge.
There are plenty of laws that govern whether a termination is proper or wrongful but that issue is not necessarily for the Commission to decide. Its their given job to decide if someone is temporarily disabled from a work related injury and not the propriety of the firing.
According to the Supreme Court, where an employee has been fired for unrelated cause by his employer, the test for deciding entitlement to ongoing TTD benefits remains whether the employee has medically stabilized or whether the employee continues to show that he is temporarily totally disabled from regular work.
Since the Commission found that this employee proved that he remained temporarily totally disabled from regular work as a result of his work injury and he proved that he had not yet reached maximum medical improvement, the Commission's award of ongoing temporary disability benefits was sufficiently supported by the evidence even in the face of an alleged "termination for cause".
This decision is not to say that the Illinois Workers Compensation Commission won't deny temporary disability benefits in the future where the facts demonstrate that some volitional act of the employee removes him or her self from light duty employment but rather, that a discharge for cause is not a basis for automatic suspension, denial or termination of temporary total disability benefits under the Illinois Workers Compensation Act
Chicago Workers Compensation Attorney -- 2-03-10
9/05/2009
Illinois Construction Workers Presumed to be Employees
New laws apply to employers and contractors in the construction industry eff., January 1, 2008. Illinois Attorney General Lisa Madigan is now prosecuting non-compliant employers under the new law. All construction workers working for construction contractors after January 1, 2008 are presumed to be employees of the contractor by law unless they meet the specific exceptions listed in (b) and (c) below as set out in Section 10 of the new Employee Classification Act.
(820 ILCS 185/10)Sec. 10. Applicability; status of individuals performing service.
(a) For the purposes of this Act, an individual performing services for a contractor is deemed to be an employee of the employer except as provided in subsections (b) and (c) of this Section.
(b) An individual performing services for a contractor is deemed to be an employee of the contractor unless it is shown that:
(1)the individual has been and will continue to be free from control or direction over the performance of the service for the contractor, both under the individual's contract of service and in fact
(2) the service performed by the individual is outside the usual course of services performed by the contractor; and
(3) the individual is engaged in an independently established trade, occupation, profession or business; or
(4) the individual is deemed a legitimate sole proprietor or partnership under subsection (c) of this Section
(c) The sole proprietor or partnership performing services for a contractor as a subcontractor is deemed legitimate if it is shown that:
(1) the sole proprietor or partnership is performing the service free from the direction or control over the means and manner of providing the service, subject only to the right of the contractor for whom the service is provided to specify the desired result;
(2) the sole proprietor or partnership is not subject to cancellation or destruction upon severance of the relationship with the contractor;
(3) the sole proprietor or partnership has a substantial investment of capital in the sole proprietorship or partnership beyond ordinary tools and equipment and a personal vehicle;
(4) the sole proprietor or partnership owns the capital goods and gains the profits and bears the losses of the sole proprietorship or partnership;
(5) the sole proprietor or partnership makes its services available to the general public or the business community on a continuing basis;
(6) the sole proprietor or partnership includes services rendered on a Federal Income Tax Schedule as an independent business or profession;
(7) the sole proprietor or partnership performs services for the contractor under the sole proprietorship's or partnership's name;
(8) when the services being provided require a license or permit, the sole proprietor or partnership obtains and pays for the license or permit in the sole proprietorship's or partnership's name;
(9) the sole proprietor or partnership furnishes the tools and equipment necessary to provide the service;
(10) if necessary, the sole proprietor or partnership hires its own employees without contractor approval, pays the employees without reimbursement from the contractor and reports the employees' income to the Internal Revenue Service;
(11) the contractor does not represent the sole proprietorship or partnership as an employee of the contractor to its customers; and
(12) the sole proprietor or partnership has the right to perform similar services for others on whatever basis and whenever it chooses.
(d) Where a sole proprietor or partnership performing services for a contractor as a subcontractor is deemed not legitimate under subsection (c) of this Section, the sole proprietorship or partnership shall be deemed an individual for purposes of this Act.
(e) Subcontractors or lower tiered contractors are subject to all provisions of this Act.
(f) A contractor shall not be liable under this Act for any subcontractor's failure to properly classify persons performing services as employees, nor shall a subcontractor be liable for any lower tiered subcontractor's failure to properly classify persons performing services as employees.
(Source: P.A. 95-26, eff. 1-1-08.)
If an employer/ contractor miss-classifies a worker as an independent contractor in violation of the new law, the Attorney General of Illinois can and will prosecute and the courts can and do assess fines, stop work orders or other remedies. The Illinois Department of Labor will also notify other State agencies such as the Department of Employment Security (unemployment taxes), the Department of Revenue (income taxes for State & Fed) and the Illinois Workers’ Compensation Commission (Workers comp insurance compliance penalties) who are all then required to review and check the contractor’s compliance with each of their own respective laws. Contractors found in multiple violations can be in a whole world of hurt.
- Jerry Ryce Builders, Inc. and Jerry Ryce Masonry, Inc., owned by Boguslaw Omielan and operating out of 3801 South Archer Chicago, Ill.; and
- J S Masonary, Inc., JS Masonry & Tuckpointing, Inc., and JS Masonry & Stone, Inc., owned by Jan Staszel and operating out of 9001 W. Deerwood, Palos Hills, Ill.
“This agreement requires these five companies to legally recognize the hard-working men and women they employ by no longer denying them the benefits to which they are entitled,” Madigan said. “Illinois businesses, especially those involved in the construction trades, should be aware that this practice – which harms workers and puts honest employers at a competitive disadvantage – will not be tolerated.”
The Illinois Workers Compensation Commission will also take notice of the new law when looking at independent contractor defenses in workers compensation construction injury claims involving actual or claimed employees. There seems to be a recent trend at the Commission to favor employment relationships in cases for injured workers in both trucking and the construction industry.
To review construction accident work injury claims, contact an experienced Illinois workers compensation attorney. The construction area and the rights of the parties are often confusing. Often, a loaned/borrowed employment relationship may exist in a construction setting which may be governed by the subcontract indemnification agreements or by the agreements for primary liability for workers compensation claims or other such hold harmless language in the construction contracts.
Chicago Workers Compensation Attorney -- 9-05-09
8/21/2009
Illinois Workers Compensation Medical Fee Schedule Seminars
8/18/2009
Mandatory Insurer Reporting User Manual Released 8-04-09
We often report on important developments involving Medicare coordination with Illinois workers compensation claims. For those following the Mandatory Insurer Reporting requirements (MIR), the Centers for Medicare & Medicaid Services (CMS) released an updated Liability and Workers Compensation Insurance User Guide Version 2 dated 8-04-09. The 225 page document is offered to help insurance carriers and administrators understand upcoming claim reporting requirements for cases involving Medicare beneficiaries.
CMS also released an "Alert" dated 7-31-09 to define who is required to report under the new law -- that is anyone that CMS terms a Responsible Reporting Entity (RRE). The definition essentially boils down to any party that is responsible to pay the claim which may include the members of insurance risk pools, self insureds companies, any company with a deductible and workers compensation insurance carriers.
This document is in draft only and is subject to revision after additional public comment. It attempts to solve the double reporting problem with companies that keep deductibles or self insured retentions (SIR) and tries to define exactly who or what entity is responsible for the claim reporting.
Chicago Workers Compensation Attorney -- 8-18-09
8/10/2009
Illinois Workers Compensation Medical 2 Doctor Rule
8-11-09
Illinois workers compensation allows injured workers to have a choice of picking two doctors for treatment. Hospital emergency care does not count as a choice of doctor but after that, if you start medical treatment with any physician, it is going to be considered as using one of your two choices for a doctor.Your initial doctor can refer you to as many specialists or therapists as are necessary to evaluate and treat your injuries. But say you have a disagreement with your 1st doctor or you feel not enough is being done to treat your injury. Section 8(a) of the Illinois Workers Compensation Act allows for a 2nd independent choice of doctor at the employer's expense under workers compensation. A third choice of doctor will not be paid for as a medical expense under Illinois workers comp to prevent doctor shopping.
All injured workers should be aware of the two doctor rule or they may find themselves paying out of pocket for medical care that should have been covered in workers compensation medical benefits. And, an Illinois workers compensation attorney will not be able to force payment of those medical bills because by law an employer is not responsible for a 3rd choice of doctor.
For a review of basic rules and Illinois workers compensation benefits, see our web site for a short article outlining basic benefits. A recent court case also reinforces the two-physician rule where a worker received some free acupuncture, it did not count as a choice of physician. See the Appellate Court's most recent decision on the 2 doctor rule at Comfort Masters (May 2008).
For further questions concerning medical treatment or workers compensation benefits contact a Chicago Workers Compensation attorney for answers and assistance. Our Attorneys at WorkComp Chicago have handled Illinois work injury claims for over 20 years with a 98% overall success rate. Aggressive Illinois workers compensation attorneys with a strong record of success in workers compensation settlements, trials and appeals.
Chicago Workers Compensation Attorney 08-11-09
Illinois Truckers as Independent Contractors or Employees; Nature of the Business Test Matters
- whether the employer dictates the person's schedule
- whether the employer pays the person hourly
- whether the employer withholds taxes
- whether the person can be discharged (fired) at will
- and most important whether the employer may control the manner in which the work is done
There is a growing trend to classify owner-drivers of trucks as employees when they work continuously for a company and that driving forms an integral part of the employers business. By the court looking to the "nature of the business" test more workers who are labeled independent contractors will be treated as employees for workers compensation and be entitled to Illinois workers compensation benefits.
The Illinois Supreme Court announced the new "integral nature of the business" decision in Roberson (May 2007)
Many Illinois workers are wrongly classified as independent contractors to save the employer from workers compensation premiums and withholding taxes. Injured workers should contact an Illinois workers compensation attorney to determine whether they should be covered by Illinois workers compensation.
For questions call a Chicago workers compensation attorney for answers and assistance with a claim for benefits at info@workcomp-chicago.com.
Chicago Workers Compensation Attorney 8-10-09
