Illinois Employers and Carriers Face New Constraints on IMEs and Shifting Pressure Toward Utilization Review

The General Assembly passed amendments to the Illinois Workers’ Compensation Act that significantly affect how employers and carriers evaluate and contest medical treatment on the basis of medical reasonableness or necessity. That bill awaits Governor Pritzker’s signature or veto.  While the changes to Section 8.7 appear modest, the revisions to Section 12 fundamentally reshape the use of independent medical examinations. Together, these provisions reflect a clear legislative preference for utilization review over IME-driven decision making, a shift that raises serious practical concerns for employers.

Section 8.7: Incremental Changes with Important Implications

The revisions to Section 8.7 do not overhaul the utilization review framework. Medical necessity determinations must still be grounded in nationally recognized guidelines, and employers must continue to rely on utilization review to support denials of care. The amendment does, however, introduce a meaningful change to treatment authorization. Certification is now valid not only for three months, but also for the “length of treatment as determined by the treating health care professional.”

This change has two practical consequences. First, it injects greater flexibility into the certification period, by tying the duration of approved care to the treating provider’s judgment. Second, it provides claimants’ counsel stronger statutory support to argue that treatment should continue beyond rigid utilization review timelines.

The amendment also incorporates terminology that tracks litigation practice by referencing the employee’s treating provider. This change is largely stylistic, but it reinforces the role of the treating physician within the statutory framework and may be cited to support deference arguments in disputed treatment cases.

These amendments underscore that utilization review was meant to carry meaningful evidentiary weight, not merely serve as a procedural step. In practice, however, that intent has not always been realized. Arbitrators frequently give limited weight to utilization review reports, and in some cases appear to disregard them altogether, even where the review complies with the Act and is grounded in accepted guidelines. For the statutory scheme to function as intended, the Commission will need to recalibrate its approach and afford utilization review the deference the legislature contemplated. Without that shift, the benefits of this framework for employers and carriers will remain theoretical rather than actual, which is a problem given the changes to Section 12.

Section 12: A Fundamental Shift in IME Use

More substantial changes appear in the amendments to Section 12, which govern employer-directed medical examinations (or IMEs). The amendment creates an entirely new procedural overlay when an employer elects to use an IME to evaluate the reasonableness and necessity of treatment instead of utilizing Section 8.7.

The most consequential change is the imposition of a strict ninety-day deadline for tendering an IME report where the Section 12 examiner addresses the reasonableness and necessity of proposed medical care. Critically, the statute does not measure those ninety days from the date of the IME or even from the date the examination is scheduled. Instead, the clock begins when the employer receives the treating provider’s records requesting the medical service. From that point forward, the employer has ninety days to complete the entire process and tender the IME report to the employee, employee’s representative (presumably counsel), and the treating provider.  Curiously, the language of the section addressing who is obligated to tender the report, the Section 12 examiner, has not changed from its prior form.  Practically, the reports are usually tendered by the employer and/or the employer’s representative.

The statute also introduces a new rebuttable presumption tied to noncompliance with the ninety-day rule. If the employer fails to meet the ninety-day requirement or otherwise comply with the procedural obligations, there is a presumption that the employer is responsible for penalties and attorney’s fees under Sections 16 and 19(l). This presumption applies both to failures to authorize treatment and failures to pay for treatment, expanding the potential exposure.

From a defense standpoint, these are both critical developments. Making immediate decisions about recommended medical care now carries real consequences which extend beyond evidentiary weight and into penalty exposure.

Further, employers previously had no statutory obligation to pre-authorize treatment, so this amendment marks a significant departure. The statute effectively transforms compliance with IME procedures into a threshold issue that must be satisfied before the substance of the opinion is even considered.

This framework front-loads decision-making and will materially change claims handling. Employers can no longer wait to see how treatment unfolds before deciding whether to pursue an IME. By the time the need for an examination becomes clear under the prior practice model, a substantial portion of the ninety-day window may already have elapsed.  The amendments also impose a due diligence obligation in obtaining records, which prevents employers from informally delaying the start of the clock.

As a practical matter, employers and carriers must identify potential disputes and decide whether to proceed with an IME almost immediately upon learning that treatment has been requested. They must also move quickly to secure records, schedule the examination, obtain a report, and ensure timely disclosure. Any delay at any stage risks running afoul of the deadline and exposing the employer to penalties and attorney’s fees. This compressed timeline will require more proactive file management and likely earlier engagement of defense counsel and medical experts than was previously typical.

The Section 12 amendments also mean that Section 8.7 may offer the most predictable and defensible path for contesting treatment, particularly where the disputed care lacks support in evidence-based medical literature. But unless the Commission begins giving meaningful weight to compliant utilization review, employers may find themselves pushed toward a mechanism that does not provide a reliable means of challenging questionable medical decisions.

This shift also raises a more fundamental concern when dealing with providers who are bad actors. Utilization review, by design, relies almost entirely on the accuracy and completeness of the treating provider’s medical records. Where a provider is thorough and accurate, that framework works as intended. However, where a provider is not, the system becomes far more vulnerable. A utilization review physician is generally limited to what is documented in the chart and cannot independently verify whether exam findings or diagnostic testing are reported accurately. In contrast, an IME provides an opportunity to independently examine the employee, review imaging firsthand, and confirm whether objective findings actually support the proposed course of care. In cases involving aggressive or unreliable treatment, that distinction matters.

A provider inclined to justify ongoing treatment can document findings to align with guideline requirements, allowing the care to pass utilization review muster despite underlying physical examination inconsistencies or inaccuracies. By making IMEs more procedurally difficult and risk-laden, the statute may unintentionally reduce one of the few tools available to challenge inflated or unsupported treatment recommendations at their source. For employers and carriers, this creates a tension between the statutory preference for utilization review and the practical need for independent medical validation in cases where the reliability of the underlying records is in question.

It should be noted that the ninety-day rule only applies where the employer asks the Section 12 examiner “for an examination of the reasonableness and necessity of medical services proposed or provided, instead of a utilization review.”  Therefore, the procedures for tendering Section 12 examination reports addressing issues of work status, causation, maximum medical improvement, or any other issue which cannot be addressed through utilization review, are not subject to the same time limitations or penalty consequences.  While some employees’ attorneys will certainly try to argue that all Section 12 reports must be tendered quickly, the plain language of the amendments clearly limits the new ninety-day rule to the limited issues which may be addressed through utilization review.

Section 12 Same-Specialty Requirement

Section 12 also imposes a new requirement that the IME physician be board certified in the same specialty as the treating provider.

This requirement will create practical complications in many cases. Treating providers often operate outside, or at least on the edges of, their formal specialties. A pain management physician may direct care involving underlying surgical spine pathology, or a primary care provider may manage conditions implicating orthopedic or neurological issues.

In those situations, strict adherence to the same-specialty requirement may result in selecting an IME physician who matches credentials but is not best positioned to evaluate the actual condition at issue. At the same time, selecting a physician who is better suited to the condition creates risk that the opinion will be challenged for failing to meet the statutory requirement. This tension is likely to produce litigation over both admissibility and weight, and will require careful, well-documented expert selection decisions.

The Emerging Preference for Utilization Review

Taken together, these amendments create a clear statutory preference for utilization review. Utilization review avoids the strict timing and procedural requirements now imposed on IMEs and is intended to serve as the primary mechanism for evaluating medical necessity. But unless utilization review is treated as meaningful evidence in practice, that preference may leave employers with fewer effective tools to challenge questionable treatment recommendations.

Practical Takeaways for Employers, Carriers, and Defense Counsel

These amendments require immediate changes in claims handling. Employers and carriers must identify treatment disputes early and make prompt decisions about whether to pursue an IME. They must track the ninety-day deadline from the moment medical records are received, act quickly to schedule examinations, and ensure timely disclosure of reports. And they must now pre-approve treatment, not just pay for it.

At the same time, utilization review will likely become the default mechanism for disputing treatment, not because it is always the most effective tool, but because it avoids the procedural risks now attached to IMEs.

Ultimately, the success of this framework will depend on whether utilization review is treated as meaningful, reliable evidence consistent with legislative intent. Without that shift, the combination of increased reliance on utilization review and stricter limitations on IMEs may make it more difficult for employers to challenge unsupported or excessive medical care.

If you have any questions about these proposed amendments, please reach out to our attorneys here.

The NBKL blog is provided for informational purposes; we are not giving legal advice or creating an attorney/client relationship by providing this information.  Before relying on any legal information of a general nature, you may consider consulting legal counsel as to your particular facts and applications of the law.