The Illinois Worker's Compensation Commission is responsible for settling disagreements between employers and their employees when Worker's Compensation disputes arise. A case is heard by an arbitrator first, and that decision may be evaluated by a panel of three commissioners. An appeal can then be made of the worker's comp case to the circuit court, Appellate Court, and Illinois Supreme Court. While most worker's compensation disputes are resolved by settlement, it is important to know your rights and speaking with an experienced worker's compensation attorney may be beneficial.
The Medical Fee Schedule for Illinois worker's compensation claims apply to medical treatments and procedures that are rendered on or after February 1, 2006 and are covered under Section 8 of the Illinois Workers' Compensation Act. The fees are calculated according to the criteria set forth in Section 8.2 of the Act. The information on this page is a brief overview intended to help individuals understand the medical fee schedule for Illinois Worker's Compensation claims and should not be construed as legal advice. If you need legal opinion, consult the personal injury attorneys at Lipkin & Apter. More details, including fee schedule documents and frequently asked medical questions can be found here.
In accordance with Sections 8(a), 8.2 and 16 of the Workers' Compensation Act [820 ILCS 305/8(a), 8.2 and 16] (the Act), the Illinois Workers' Compensation Commission Medical Fee Schedule, including payment rates, instructions, guidelines, and payment guides and policies regarding application of the schedule, is adopted as a fee schedule to be used in setting the maximum allowable payment for procedures, treatment, products, services or supplies for hospital inpatient, hospital outpatient, emergency room, ambulatory surgical treatment centers, accredited ambulatory surgical treatment facilities, prescriptions filled and dispensed outside of a licensed pharmacy, dental services and professional services covered under the Act.
For procedures, treatments, services or supplies covered under the Act and rendered or to be rendered on or after September 1, 2011, the maximum allowable payment shall be 70% of the fee schedule amounts, which shall be adjusted yearly by the Consumer Price Index-U. The payment rates in the fee schedule are designated by geozip (geographic areas in which all zip codes have the same first 3 digits). Starting January 1, 2012, the payment rates in the fee schedule shall be grouped into geographic regions pursuant to Section 8.2 of the Act.
The fee schedule includes the following service categories:
- Ambulatory Surgical Treatment Center (ASTC) and Accredited Ambulatory Surgical Treatment Facility )ASTF)
- On and after September 1, 2011 and until the Commission posts a fee schedule for dental bills, all dental bills shall be paid at 53.2% of actual charge unless the services are billed under the HCPCS Level II schedule in subsection (h)(5) or professional fee schedule in subsection (h)(8).
- Emergency Room
- Procedures, treatments and services subject to this schedule rendered on or after September 1, 2011 are reimbursed at 53.2% of actual charge.
- Healthcare Common Procedure Coding System (HCPCS) Level II
- Hospital Inpatient: Standard and Trauma
- Inpatient care shall be defined as when a patient is admitted to a hospital where services include, but are not limited to, bed and board, nursing services, diagnostic or therapeutic services, and medical or surgical services.
- Hospital Outpatient
- This schedule includes radiology, pathology and laboratory, and physical medicine and rehabilitation as well as surgical services performed in a hospital outpatient setting that were not performed during an emergency room encounter or inpatient hospital admission.
- Professional Services
- Services in this schedule include evaluation and management, surgery, physician, medicine, radiology, pathology and laboratory, chiropractic, physical therapy, and any other services covered under the Current Procedural Terminology.
- Rehabilitation Hospitals
- This schedule applies to inpatient rehabilitation hospitals that are freestanding.
- This schedule applies to prescriptions filled and dispensed outside of a licensed pharmacy. Prescriptions shall be billed at the Average Wholesale Price, plus a dispensing fee of $4.18. [820 ILCS 305/8.2(a-3)].
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