The IWCC’s updated Medical FAQS does have information on the new medical fee schedule effective dates:
· Out of State Provider Reimbursement: An out-of-state provider will receive the lesser of that state's fee schedule amount or the fee schedule amount for the region in which the injured employee resides. If the provider’s state does not have a WC fee schedule, the provider will receive the lesser of the billed charge or the fee schedule amount for the region in which the employee resides.
· Provider Payment Time Frames: The bill payment window is now 30 days from the receipt of the bill (reduced from the previous requirement of 60 days), as long as the bill contains substantially all required data elements. Employers or insurers must explain the basis for denial or send notification of any missing required data elements within 30 days of the receipt of the bill.
· 30% Reduction in Provider Reimbursement: The maximum allowable payments for all listed flat rate codes will be 70% of their current state fee schedule reprice amounts.
o POC76 codes, codes where a schedule amount cannot be determined, will reimburse at 53.2% (currently 76%) of billed charges.
o Non-implant “pass through codes” remain at 65% of billed charges.
o Implant “pass through codes” will reprice according to the new implant repricing methodology.
· Implant Repricing Methodology: Implants will reimburse at 25% above the net manufacturer’s invoice price less rebates, plus actual reasonable and customary shipping charges. (The IWCC Medical FAQ originally listed this effective date as 6/28/11, it was updated on the IWCC website on 7/29/11)
· Prescription Fee Schedule: The IWCC’s Fee Schedule Committee will create a new fee schedule for prescriptions filled and dispensed outside of a licensed pharmacy that will not exceed the Average Wholesale Price (AWP) plus a dispensing fee of $4.18.
· New Geographic Regions for Provider Reimbursement
o 4 Regions for “Non-Hospital Fee Schedule Amounts”
o 14 Regions for “Hospital Fee Schedule Amounts”
o If a geozip overlaps into 1 or more of the regions, the Commission shall average or repeat the charges and fees in a geozip in order to designate charges and fees for each region.
o According to the preliminary discussion and interpretation at the 6/14/11 IWCC Medical Fee Advisory Board meeting, the fee schedules define “hospital” according to the IDPH hospital definition.
The next Medical Fee Advisory Board meeting is scheduled for August 23 at 9:00am. That meeting should provide additional clarifications about the implementation methodologies for all of the reforms in HB 1698. Hopefully, the Board will also provide additional information about how Glen Boyle (the Fee Schedule Project Manager) and his team are determining and recalculating the fee schedule reprice amounts for both the new Hospital & Non-Hospital fee schedule regions effective 1/1/2012. This is a major undertaking that will have a profound impact on provider reimbursement.
Please feel free to use the comments section, or email us directly, with any questions about the new repricing methodologies or the IL WC system in general.