June 2026; New Legislative Changes to IL WC Act Arrive; New Odd Strategy Claimant Attorneys May be Trying to Rein in IME sites and more

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Synopsis: Legislative Alert!!!Illinois Lawmakers Fiddle with the IL Workers’ Compensation Act. IL WC Medical Defenses Now More Perilous for Illinois Employers. Thoughts and Research by John P. Campbell and Eugene F. Keefe

The Illinois General Assembly recently passed House Bill 5228, introducing significant changes to the Illinois Workers’ Compensation Act. These revisions will greatly impact how employers, claims professionals, and attorneys on both sides manage and defend claims in this state, as explained below. This will not become law unless and until the Governor signs it—he has 60 days to do so.

 

Editor’s Comment: Every five or six years we see some tinkering to our IL Workers’ Compensation Statute. While this round of changes are few, perhaps the most significant change this time involves the Section 12 Examination process, often called the independent medical exam (IME).

 

Please note there may now be three distinctly different IME’s in the IL WC matrix:

 

  • IME’s that deal with reasonableness and necessity of provided or proposed care:

  • IME’s that deal with solely with causation;

  • IME’s that deal with disability ratings/return to work issues when MMI has been reached.

 

Under the revised statute, with regard to IME’s that relate, in whole or in part, to reasonableness and necessity of medical care, IL employers and insurance representative are effectively “on the clock”. An IME must be completed and report tendered to Petitioner and/or their representative and the treater within a 90-day timeframe. Of note, statutory language specifically indicates that the report“shall be provided by the medical practitioner to the employee or employee’s representatives and the employee's treating healthcare professionals within 90 days.” This appears to compel the IME physician to tender the report directly to Petitioner. Moreover, the 90-day period begins when the employer receives the medical records from the treating healthcare professional requesting the medical service. As such, Respondents are afforded time to gather the relevant records needed to perfect the exam.

 

Nevertheless, this new 90-day window creates a time crunch for the employer or claim representative to obtain an IME. Respondents must also carefully track the date medical records were received and be mindful of the need to turn around an IME report in 90 days. Finding board-certified IME physicians who acknowledge and comply with this tight turnaround time may prove an additional challenge. 

 

It is also worth noting that according to the revised statute addressing Utilization Review, “A report made under Section 12 is not a valid utilization review and shall not be used to determine the appropriateness, medical necessity, reasonableness, or quality of treatment.” This is an important change, as the statute previously outlined an IME under Section 12 as one form of utilization review. That appears to no longer be the case. We also feel this legislative language is confusing for the average claims handler or risk manager. Send a reply if you have questions.

 

Moreover, as we indicate above, IME physicians must now be board-certified in the same specialty as the treating healthcare professional requesting approval for recommended medical care. If the employer fails to comply with these new rules after receiving medical records from the treating healthcare professional, or blows the 90-day deadline for production of the IME report, there is a rebuttable presumption that the employer shall be responsible for the payment of additional compensation under the Section 16 and 19 penalty provisions under The Act. That said, as you may know penalties and fees are calculated on benefits that aren’t being paid—if you and your company/TPA are up to date on benefits, the Section of the new legislation is nonsensical. However, in cases where a surgery has been performed on a disputed basis, and the charge is outstanding, this 90 day window applies to perfect an IME to maintain denial of the procedure performed. 

 

Please also note, this 90-day turn-around appears to apply only to an IME that addresses reasonableness and necessity of care (past or proposed care). Therefore, if an IME is ordered at the end of a claim to address, say, return to work function and/or an impairment rating, this 90 day deadline is not applicable pursuant our reading of the plain language of the statute.

 

The more difficult question is whether an IME challenging causation is beholden to the 90-day reporting deadline. For example, if the IME determines a medical condition is unrelated to the work injury, the treatment may be denied by Respondent in reliance of the IME, but not due to the “reasonableness and necessity” of the proposed procedure. The denial has nothing to do with whether treatment is needed. In such a case, it is unclear whether the new statutory provision would require the same 90 day turn around.

 

Who is going to pay for this new legislative requirement?

 

As the IME report in a “reasonableness and necessity” opinion is going out from the IME doc in four different directions—do all four parties split the cost? We are certain this is a new issue that isn’t addressed at all in the new proposed law.

 

We are confident the rebuttal to shared IME cost(s) from the Claimant bar will simply assert that the party who ordered the exam must pay for the exam/report and copying/transmission/FedEx, just as before this new law. On the other side of that argument is the fact the employer/insurance carrier/TPA ordered the IME document, owned it and only had to disclose in limited circumstances.

 

Traditionally, the IME doctor has a reasonable and healthy fee for the exam and report combined. It has traditionally been one fee. The doctor may not turn it over to any party before he or she is paid, but we feel the secret parties-that-be-who run the IWCC feel Petitioner is not going to pay anything for the IME report, just as before. I believe they feel doctors will copy and send four reports and only charge Respondent for the newly required handling/copying/mailing.

 

As John Campbell reads the statute, it is simply adding a deadline to complete the IME process and tender four reports—three of which will be sent for “free.” If Respondent fails to pay for the IME, John is sure the doctor will not turn it over, even if the 90 days expires.

 

There is no penalty to the doctor, but Respondent may bear the ramifications if the doctor fee is not paid and a report is not tendered. Therefore, I think our more sound advice is for the Respondents to be sure the IME fee is paid timely so the report is not delayed.

 

UR Re-Done in IL WC

 

In addition, there are similar changes to Section 8.7 of the Act regarding utilization review. Just as required by an IME physician, a utilization review medical provider must have a current certification by a recognized American specialty board in the area appropriate to the subject of review. Further, any certification or non-certification shall be valid for 3 months after the date which the employee and healthcare provider receives certification.

 

Section 8.7 now specifically excludes a Section 12 IME exams as a form of Utilization Review and further asserts that “Any other denial or refusal of the necessity of medical services except by utilization review constitutes unreasonable and frivolous delay” This language appears contradictory to the provision in Section 12, where IME’s are often employed to specifically address the reasonableness and necessity of medical services. 

 

We do feel UR providers will quickly catch up to these new challenges.

 

Summary

 

Absent an effective date, we should assume these changes will be in effect upon signature by the Governor. We further expect these changes will apply to both pending and future claims where an IME has not yet been perfected. Therefore, our best advice is to implement a new protocol for IME’s ASAP to meet this 90 day requirement.  Any current claim where an IME is being contemplated, Respondents should presume the 90-day clock has begun to run on the need to produce an IME report, once you have all relevant treatment records necessary for the exam.

 

Finally, for our readers in the trenches of day-to-day claim handling, it is important to also note the new bill increases the burial expense on death claims from $8,000 to $10,000.

 

We appreciate your thoughts and comments, please post them on our award-winning blog.

 

 

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Synopsis: New and Irritating IME trend that may be coming to an IL WC claim you are managing.

 

Editor’s comment: We have recently seen notes from a treating doctor that summarily finds a Claimant cannot travel 

 

  • Short distances or

  • Any distance

 

Due to injury. It appears clear this physician is probably being coached to write this note. In using this path, the treating doctor is blocking access to doctors/surgeons and specialists outside of the immediate area where Claimant resides.

 

We are letting the IL WC defense industry know this laughable idea is probably coming at you soon. Our suggestion is to make clear there is no part of the IL WC Act or Rules that provides a “limit” on how far an injured claimant has to travel for medical care or an IME.

Two other thoughts in response:

  • Have the IME doctor go to Claimant’s home (we said it was a thought!!) or

  • Do a remote IME in the appropriate case with Arbitrator approval. 

We appreciate your thoughts and comments, please post them on our award-winning blog.