The Circuit Court of Cook County addressed an increasingly common – and expensive – dispute between providers and payors concerning surgery facility fees, and found that the payor’s interpretation of the fee schedule was correct.

CMS released some data for their WCMSA approvals over the last three years. The data suggests that CMS increased the proposed WCMSA amounts by 14% on average, and shows that the number of WCMSAs submitted to CMS each year are trending down. Despite the limited data provided, there are other potential implications for WCMSA submitters.

The United States Supreme Court (SCOTUS) found in favor of the employee group health plan (Marietta) and rejected the dialysis company's (DaVita) claims that the Plan discriminated against patients with ESRD.

On June 13, 2022, Chairman Michael Brennan of the Illinois Workers’ Compensation Commission (IWCC) signed an Order increasing the reimbursements for Evaluation and Management (E/M) codes by 15% across all Fee Schedule regions effective September 1, 2022.

The United States Supreme Court (SCOTUS) is set to decide a case concerning what qualifies as a conditional payment, and the ability of health care providers to utilize the Private Cause of Action (PCA) in the context of a health plan’s alleged discrimination of Medicare-eligible patients.

Two state insurance guarantee funds challenged CMS’ definition of a “primary plan” in order to exclude themselves from conditional payments and Section 111 reporting requirements.

On May 21, 2020, amendments to the Illinois Occupational Diseases Act created a rebuttable presumption in favor of compensability for COVID-19 first responders and front-line workers  who contract COVID-19; the expansive definition of “front-line workers” is based on occupations identified in the Governor’s Executive Order 2020-10 and includes employees of grocery stores, banks, postal workers, public transportation, hardware stores, etc. provided that their occupation required them to encounter members of the general public or to work in locations of more than 15 employees. 

On October 5, 2020, CMS released version 3.2 of its Workers’ Compensation Medicare Set-Aside (WCMSA) Reference Guide.

One of the most significant cost-drivers in MSAs can be surgeries.  In addition to CMS becoming more aggressive in allocating for surgeries, we have recently seen the costs of these procedures increase as well. 

In 2015, CMS announced it would be requiring responsible reporting entities (RREs) to begin using ICD-10 diagnosis codes in Section 111 reports for accidents occurring on or after October 1, 2015.