Illinois Gov. J.B. Pritzker signed legislation Friday that makes significant changes to workers compensation medical reviews, insurer assessments and penalties for licensed businesses that fail to maintain coverage.
H.B. 5228, which took effect immediately and passed both chambers in April and May, requires that adverse utilization review determinations for services delivered or recommended by a physician be made by a physician. The reviewing doctor must be appropriately board-certified and experienced in treating the condition under review.
Medical treatment certifications will remain valid for three months after the worker and provider receive the decision or for the treatment period determined by the worker’s health care provider. Surgery certifications will include three months of postoperative care, when clinically indicated, or the provider-determined treatment period, according to the bill.
The law also establishes an appeals process for treatment non-certifications. Appeals involving physician-recommended services must be reviewed by a physician with appropriate board certification and experience treating the condition.
Employers that use a medical examination to assess the reasonableness and necessity of proposed or provided treatment instead of utilization review must provide the examination and report to the worker, the worker’s representative and treating provider within 90 days of receiving the medical records.
The examining practitioner must be board-certified in the same specialty as the treating provider. Failure to comply creates a rebuttable presumption that the employer is responsible for additional compensation, including in cases of failure to authorize, approve or pay for treatment.
The law subjects businesses holding state licenses that require proof of workers comp coverage to civil penalties if they fail to maintain coverage. A business can avoid penalties by showing, through clear and convincing evidence, that it was not operating while its license was active.
The measure also increases the burial benefit for workers killed in job-related accidents from $8,000 to $10,000.
Additionally, workers comp insurers reporting underwriting gains will pay an assessment to support the Illinois Workers’ Compensation Commission Operations Fund. The funding target is $7 million for 2026 and will increase 3.5% annually.
This article was first published by Business Insurance.
