The Illinois’ Department of Insurance (the Department) recently enacted changes to the “Workers’ Compensation Electronic and Standardized Paper Billing” regulations in order to implement Public Act 100-1117, which amended Sections 8.2 and 8.2(a) of the Illinois Workers’ Compensation Act (the Act). The amendments to both the Act and corresponding regulation have created several pertinent changes to the electronic billing process. Effective August 19, 2019, for a medical bill to be considered complete and reimbursable under the Act, healthcare providers are only responsible for including the minimally necessary documentation under the current version of [HIPAA] for the bill possessed by the provider. Complete bills include, but are not limited to, medical reports and records pertaining to the provider’s claims.
In addition to the changes regarding requirements for medical bills, the Department shall impose an administrative fine, not to be greater than $1,000 and not to exceed $10,000 for identical violations during the same calendar year, if it determines that a payer has failed to comply with the electronic claims acceptance and response process under the Act. Under the rule, a payer’s violation of an applicable requirement occurs only once per medical bill. A “medical bill” includes duplicates but does not include corrected medical bills which are considered a new original bill. Identical violations are considered multiple violations of the same requirement under the Act or the regulations, but for different medical bills.
For Illinois employers and payers under the Act, the new requirements will make it easier for providers to send their bills electronically and be reimbursed without having to provide a patient’s full medical record. However, there is less flexibility for payers to argue that bills are not reimbursable due to a failure to contain all the necessary data elements, meaning that a refusal to reimburse is more likely to expose a payer to Section 8.2(d)(3) interest under the Act for failure to pay or object a complete bill within 30 days of receipt, or to administrative fines. However, the rule specifies that a payer will not be assessed a fine for a late payment violation, but instead, will be subject to an interest penalty as provided by Section 8.2(d)(3) of the Act unless one month of interest has accrued.
Please make sure to read about the additional rule changes under Public Act 100-1117 and the recently proposed IWCC rules defining “Explanation of Benefits.”
Feel free to contact Nyhan, Bambrick, Kinzie, & Lowry with any further questions.