Dealing with Unpaid Medical Bills in Illinois WC

Wednesday, June 23, 2010 | 0

By Eugene Keefe
Keefe Campbell & Associates

There is a clear path for submission of medical bills in this state and we want medical providers and other observers to start to think about following it. The Illinois Workers’ Compensation Act contemplates medical bills for care incurred which the patient claims are reasonable, necessary and related to the work injury be submitted to the insurance carrier/third-party administrator who is assigned the adjustment of the claim, whether it is accepted or disputed.
 
We suggest the parties on both sides of this problem, both the medical provider and the insurance carrier/TPA have HIPAA-compliant releases that should outline the proper federal medical privacy standards. We do not recommend anyone rely on the supposed “workers’ compensation exception” to HIPAA—it is too unreliable.
 
How do you find out the injury/disability claim and related medical treatment is being made under workers’ compensation? Ask the patient.
 
Once the patient advises you of that fact, the next inquiry is the name and address of the employer. If you have the name and address of the employer, you may be able to do several things toward getting bills submitted for processing. First, ask the employee to look at the state-required notice posted in their workplace in relation to workers’ compensation—ask them to look at the bottom and get the name/address of the workers’ compensation carrier. Second, you can call and/or send the bills to the risk manager at the patient’s employer and ask them to submit them. Third, you can call and ask the name/address of the employer’s workers’ compensation carrier or TPA. Fourth, you can check the Illinois Workers’ Compensation Commission’s website for the name and address of the carrier.
 
Next, be sure you submit the medical bills to the employer or insurance carrier in the proper form with proper documentation. In order to reconcile bills to the Illinois medical fee schedule they are needed in HCFA1500 form. In order to expedite the process we always ask for any medical bills from any provider to be in this form to save lots and lots of work later. We have a paralegal that has a medical bill payer background and can price and process Illinois WC medical bills but still needs the billing on this form.
 
What is supposed to happen following proper submission? Well, Rule 7110.70 of the Illinois Rules Governing Practice indicates they are supposed to pay the bills or tell you why they aren’t.
 
The rule states (in part):
 
When an employer denies liability for payment of the cost of all or a part of an employee's medical care, or initially accepts liability but subsequently declines further responsibility for providing or paying for all or a part of such care (for any reason including but not limited to the necessity or propriety of the care, or continuing care, or the unreasonableness of the cost of care), the employer shall promptly notify the employee with a written explanation of the basis for the denial of liability or further responsibility.
 
e) Failure by either party to comply with the provisions of subsection (a), (b), (c) or (d) of this Section, without good and just cause, shall be considered by the Commission or an Arbitrator when adjudicating a petition for additional compensation pursuant to Section 19(l) of the Act, or a petition for assessment of attorneys' fees and costs pursuant to Section 16 of the Act.
 
Again, if they accept the bill and pay it, you are good to go. What do you do if they fight it, ignore you or deny it?
 
Well, you need to remain diligent. If the matter is disputed by the employer, the applicable rule states:
 
When there is a dispute over the compensability of or amount of payment for a procedure, treatment, or service, and a case is pending or proceeding before an Arbitrator or the Commission, the provider may mail the employee reminders that the employee will be responsible for payment of any procedure, treatment or service rendered by the provider. The reminders must state that they are not bills, to the extent practicable include itemized information, and state that the employee need not pay until such time as the provider is permitted to resume collection efforts under this Section. The reminders shall not be provided to any credit rating agency. The reminders may request that the employee furnish the provider with information about the proceeding under this Act, such as the file number, names of parties, and status of the case. If an employee fails to respond to such request for information or fails to furnish the information requested within 90 days of the date of the reminder, the provider is entitled to resume any and all efforts to collect payment from the employee for the services rendered to the employee and the employee shall be responsible for payment of any outstanding bills for a procedure, treatment, or service rendered by a provider.
 
Sounds simple, doesn’t it? In layman’s terms, keep sending notices consistent with the law.
 
What does a medical bill provider do if you find out the claim has settled and you haven’t been paid? Well, our rule is pretty simple. If the insurance carrier/TPA knew about either the medical bill or treatment, it needed to have been addressed at the time of settlement as accepted or disputed. You should have the documentation listed above to be able to demonstrate to the insurance carrier/TPA and counsels for both sides of your efforts to make them aware and keep them aware of your interest in the claim. If the only notice of the bill was to the patient/employee, you may have a problem.
 
If the insurance carrier/TPA can demonstrate a complete lack of knowledge of a medical bill or course of medical care prior to settlement of the claim, we find it difficult to believe they would be held responsible for it and our typical recommendation is to deny the claim.

Eugene Keefe is a principal at Keefe Campbell & Associates, a Chicago workers' compensation defense firm. This column was reprinted with his permission from the firm's client newsletter.