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Illinois Workers’ Compensation Act Prohibits Balance Billing

Daniel Klosowski

undefinedOne of the main benefits that an injured employee is entitled to in workers’ compensation is payment of medical bills incurred as a result of the work accident. The workers’ compensation insurance carrier is required to satisfy all of the medical bills which are related to the work accident. When having bills paid through the insurance carrier, all of the bill must be paid by that insurance company. Unlike medical bills paid by a group health insurance carrier, there is no requirement that a co-pay or a deductible or any other out-of-pocket costs be paid by the injured employee.

The fees that a doctor can collect for treatment for a workers’ compensation injury are controlled by what is called a “medical fee schedule.” The medical fee schedule was implemented as part of the amendments to the Illinois Workers’ Compensation Act which took effect on February 1, 2006. Prior to this date, the workers’ compensation insurance carrier was required to pay the reasonable amount that was charged by the doctor, whatever that charge may have been. The medical fee schedule established that the maximum allowable payment for medical treatment to be the lesser of the healthcare provider’s actual charges or the fee set in the schedule. The fee schedule amount, in its most basic sense, is an average of the fees charged for any particular procedure in a geographic area. This has resulted in the amount that is paid to a healthcare provider according to the medical fee schedule being less than the originally charged amount in some instances.

Some healthcare providers have attempted to collect the difference between what was originally charged for a procedure performed on an injured employee and what was paid to the provider according to the medical fee schedule. The Appellate Court of Illinois for the Fourth District addressed this question in a case that was decided in September 2013. In that case, an injured worker had received treatment at a chiropractic clinic. The chiropractic clinic had the injured employee sign a document stating that full payment would be made by the injured employee for the chiropractic care. The chiropractic clinic then submitted bills for payment to the workers’ compensation insurance carrier. As part of the settlement for the claim, the workers’ compensation insurance carrier agreed to pay the outstanding bills from the chiropractic clinic according to the medical fee schedule. Once these payments were made, a balance of approximately $2,000.00 remained.

The chiropractic clinic filed a lawsuit against the injured employee and the employer for payment of the $2,000.00. The Appellate Court ruled that the injured employee was not responsible for this $2,000.00 remaining balance. The chiropractic clinic was not entitled to any payment for this outstanding balance because the workers’ compensation insurance carrier had made payments according to the medical fee schedule. This was a positive result for injured employees whose healthcare providers charge more than the medical fee schedule amount. As stated above, a major benefit for injured employees is to have medical bills that result from a work accident paid by the insurance carrier. It is important to contact an attorney experienced in workers’ compensation if you are being billed.

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