Making Sense of how Medical Bills are to be Handled in Illinois

Tuesday, August 3, 2010 | 0

By Eugene Keefe
Keefe Campbell & Associates

Editor’s comment: We are certain there were lots of changes to the Illinois Workers’ Compensation Act in 2005. We are fairly confident it hasn’t caught up to doctors, hospitals and other health care billers. We do feel the recent ruling from the Appellate Court in Holtkamp may affect what is happening out there and wanted to give you our thoughts.

Plan A, we urge everyone to remember one thing, if a claim is accepted bills are to be sent to the employer or insurance carrier/third-party administrator — take the worker out of the loop and bill the employer or its carrier/TPA directly. The Act says:

Section 8.2 (d)

<i>When a patient notifies a provider that the treatment, procedure, or service being sought is for a work-related illness or injury and furnishes the provider the name and address of the responsible employer, the provider shall bill the employer directly. The employer shall make payment and providers shall submit bills and records in accordance with the provisions of this Section. All payments to providers for treatment provided pursuant to this Act shall be made within 60 days of receipt of the bills as long as the claim contains substantially all the required data elements necessary to adjudicate the bills. In the case of nonpayment to a provider within 60 days of receipt of the bill which contained substantially all of the required data elements necessary to adjudicate the bill or nonpayment to a provider of a portion of such a bill up to the lesser of the actual charge or the payment level set by the Commission in the fee schedule established in this Section, the bill, or portion of the bill, shall incur interest at a rate of 1% per month payable to the provider.</i>

This sounds pretty simple to us. If the medical care/treatment is for a work-related injury, the medical caregiver has to get the name of the employer and/or insurance carrier/TPA from the patient. When you have it, send the bills and records to that contact from then on. Don’t send them to the patient.

So, who pays for the copies of original medical records being sent to the “employer” or insurance carrier/TPA? Who pays for “substantially all the required data elements necessary to adjudicate the bills” as the statute says? Well, under Holtkamp, it says you cannot force the healthcare giver to make free records or unlimited records for a $20 witness fee but you can agree on whatever is fair. Our vote is for the medical caregiver to send/fax/pony express free bills and free records and free whatever, so long as you are getting paid in a timely fashion. You don’t necessarily have to make a complete copy of your entire patient chart, but if you are seeking to get paid for surgery, send the surgical report and other supporting tests and data. Then start adding 1% per month to outstanding balances.

Plan B, what is supposed to happen if there is a fight? What do you do if the accident injury isn’t accepted under WC but the employee is litigating the issue? Can the medical caregiver still continue to seek payment? Well, the law says:

Section 8.2(e-15)

<i>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.</i>

Again, this procedure seems clear and concise and it doesn’t take a rocket scientist to follow it. Following the first section above, get the name of the employer or insurance carrier/TPA. As the patient and the contact with the insurance carrier/TPA:

Are our bills accepted? If so, follow the first section cited above.

If the bills are disputed, follow Plan B and start sending reminders to everyone. Diary your file ahead every ninety days to continue to follow up.

Plan C—What does the health care provider do if the matter settles between the patient and the insurance carrier/TPA and you are left out of the loop? Well, that is becoming more and more common in Illinois. What we are telling the healthcare providers to do is to then start normal collection procedures against everyone—go after the patient, employer, insurance carrier/TPA.

In Hagene v Derek Polling Construction, some of the bills were not paid and remained in dispute after approval of settlement and closure of the claim. The front of the contracts had the box checked to indicate “all medical bills” were paid and the back of the contracts said the settlement was a compromise of all benefits owed under the Act. In contrast, the claim for TTD said it was disputed on the front and to refer to the reverse of the document for settlement terms. After settlement, the patient learned almost $20K in medical expenses incurred prior to settlement remained unpaid by the employer, insurance carrier/TPA or anyone else. The Appellate Court ruled the settlement included all related medical bills.

If the contracts did not have the box checked on the front and the reverse of the contracts indicates all bills were claimant’s sole responsibility; the medical caregiver should be able to recover from the patient in typical collection litigation. Either way, we urge you to avoid that by making sure to continue to send ninety-day reminders to the patient, the employer, insurance carrier/TPA and lawyers for both sides.

<i>Eugene Keefe is a partner with Keefe, Cambell & Associates, a Chicago workers' compensation defense law firm. This column was reprinted with his permission from the firm's client newsletter.</i>