2011 Illinois Workers Comp Reform Employer PPO Plans

2011 Illinois Workers Comp Reform Employer PPO Plans

 By Brad Bleakney, Esq.

The Illinois Workers Comp Reforms of 2011 offer major changes which are too many to list in a single post but I will try to cover the summary of major changes in future posts.

The two biggest changes under the 2011 Illinois Workers Comp Reforms are 1) reduction of the Medical Fee Schedule rates by 30% and 2) the introduction of employer PPO plans approved by the IL Dept of Insurance that attempt to limit the employer's liability for medical treatment.

A fellow workers comp attorney in Texas asked whether the Opt-Out provision for our new workers comp PPO plans was big enough to drive a truck through and I provided my answer in typical lawyerly fashion by proceeding to qualify my answer. The easy answer is the employer has "1st dibs" on medical treatment by adopting workers comp PPO plans.

The injured worker can only "Opt-Out" of the employer's PPO plan in writing and before exhausting their 2 choices of doctor in network. After using up 2 choices of physicians within the PPO network, the injured worker can only request a hearing at the Commission for a finding on the "adequacy of care" to see if they are allowed to go out of network.

The not so obvious medical treatment options following the new reforms are:

(1) if the employer has no PPO provider, the employee retains the right to choose 2 doctors;

(2) if the employer has an Illinois workers comp PPO plan and notifies the injured employee of the PPO plan in writing, soon after receiving the report of injury, injury treatment options are limited to the PPO plan or;

(3) if the employee declines the PPO and Opts-out (in writing) before treating with the PPO plan, the worker automatically loses 1 choice of doctor and has only 1 choice of doctor left to go outside of network

(4) if the employee "opts out" (in writing) after initial treatment by a PPO plan doctor, they also have only 1 choice of doctor left to go outside of network;

(5) if the employee stays in network and uses up both choices of doctor in network, they have no doctor choices left -- they can only go outside of network upon a hearing at the Commission and after a finding of "improper or inadequate" medical care.

All medical care for an injured Illinois worker is limited in some fashion by the introduction of PPO plans in the new reforms. Needless to say this is a huge boon to Illinois medical provider networks that qualify as PPO providers through the Illinois Department of Insurance.

All workers that use up their 2 choices of doctor within the PPO plan (which I suspect will happen quite often) are severely restricted as they have no rights outside of the PPO plan absent a hearing on the adequacy of care at the Commission. I should say that injured workers can still pay out of pocket as an option at any time without expecting reimbursement but that is not going to happen all that often.

The rules for medical providers qualifying for the new PPO plans are not set out yet and the Commission has yet to develop forms for "Notice of PPO Plan" for employers to notify injured workers of the PPO plan nor are rules created yet to deal with hearings on adequacy of medical care as this package of major workers compensation reforms just unfolded on May 31, 2011 when the measures of HB1698 passed the Illinois House of Representatives to go to Governor Quinn for signature.

Let me quote the relevant Opt-Out section for non-believers and nay sayers:

8a(4)(B) " …the employee may choose in writing at any time to decline the preferred provider program,.. which …would constitute one of the two choices of medical providers to which the employee is entitled"

Note:

1) the opt out must be in writing; and

2) even the act of "opting out" uses up 1 choice of doctor, so the injured worker has only 1 choice of doctor left after opting out of the employer's workers comp PPO plan thereby limiting doctor shopping.

As I see it -- besides the 30 % reduction on the medical fee schedule for out of network providers, the introduction of workers comp PPO plans is the biggest reform in decades and the biggest money saver for Illinois employers in the 2011 package.

All savvy employers will now sign up for PPO plans to get contract discount rates below the medical fee schedule and the injured worker loses 1 choice of doctor under the ILWC Act no matter what they do if the employer has a PPO plan.

The injured worker can certainly select 2 choices of doctor inside the PPO plan but never 2 choices outside the PPO plan. If the injured worker opts out of the PPO plan it must be in writing -- so in my reading of the changes, a lot of injured workers who go to their own family doctor outside of the PPO plan without sending a written notice "opting out" to the employer as required will find themselves coming out of pocket.

As I see it, PPO plans are a double bonus for Illinois employers -- contract medical fee discounts and restrictions on doctor shopping by injured workers -- this will likely result in big savings for Illinois employers over the present options for medical care. The reforms restrict the rights of injured workers to select medical providers but that is a political and social compromise reached to attract new JOBS and make Illinois more "business friendly" going forward. Non network medical providers and injured workers were the biggest losers this round but it could have been much worse for both.

Questions?? Call an Illinois workers compensation lawyer for answers. We can gaze at our crystal ball to look for answers on the implications of the new Illinois workers comp reforms and provide individual instruction.

CAVEAT: The bill is not yet signed into law and is awaiting the Governor's signature -- the final provisions could still be subject to change. To see a list of the major reforms, click here.

© Copyright 2011 by Work Comp Chicago. All rights reserved. This article, which appeared on the Illinois Workers Compensation Blog, has been reprinted with permission.

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