Wis. Admin. Code Department of Workforce Development § DWD 80.73 - Health service necessity of treatment dispute resolution process
(1) PURPOSE.
The purpose of this section is to establish the procedures and requirements for
resolving a dispute under s.
102.16(2m),
Stats., between a health service provider and an insurer or self-insurer over
the necessity of treatment rendered by a provider to an injured
worker.
(2) DEFINITIONS. In this
section:
(a) "Dispute" means a disagreement
between a provider and an insurer or self-insurer over the necessity of
treatment rendered to an injured worker where the insurer or self-insurer
refuses to pay part or all of the provider's bill.
(b) "Expert" means a person licensed to
practice in the same health care profession as the individual health service
provider whose treatment is under review, and who provides an opinion on the
necessity of treatment rendered to an injured worker for an impartial health
care services review organization or as a member of an independent panel
established by the department.
(c)
"Licensed to practice in the same health care profession" means licensed to
practice as a physician, psychologist, chiropractor, podiatrist or
dentist.
(d) "Provider" includes a
hospital, physician, psychologist, chiropractor, podiatrist, physician's
assistant, advanced practice nurse prescriber, or dentist, or another licensed
medical practitioner who provides treatment ordered by a physician,
psychologist, chiropractor, podiatrist, physician's assistant, advanced
practice nurse prescriber, or dentist whose order of treatment is subject to
review.
(e) "Review organization"
or "impartial health care services review organization" means a public or
private entity not owned or operated by, or regularly doing medical reviews
for, any insurer, self-insurer, or provider, and which, for a fee, can provide
expert opinions regarding the necessity of treatment provided to an injured
worker.
(f) "Self-insurer" means an
employer who has been granted an exemption from the duty to insure under s.
102.28(2),
Stats.
(g) "Treatment" means any
procedure intended to cure and relieve an injured worker from the effects of an
injury under s.
102.42,
Stats.
(3) NOTICE TO THE
PROVIDER.
(a) In a case where liability or
the extent of liability is in dispute, an insurer or self-insured employer
shall provide written notice of the dispute to the health care provider within
60 days after receiving a bill that documents the treatment provided to the
worker, unless there is good cause for delay in providing notice. An insurer or
self-insurer which refuses to pay for treatment rendered to an injured worker
because it disputes that the treatment is necessary shall, in a case where
liability or the extent of liability is not an issue, give the provider written
notice within 60 days of receiving a bill which documents the treatment
provided to the worker. The notice shall specify all of the following:
1. The name of the patient
employee.
2. The name of the
employer on the date of injury.
3.
The date of the treatment in dispute.
4. The amount charged for the treatment and
the amount in dispute.
5. The
reason that the insurer or self-insurer believes the treatment was unnecessary,
including the organization and credentials of any person who provides
supporting medical documentation and a copy of the supporting medical
documentation from that person.
6.
The provider's right to initiate an independent review by the department within
9 months under sub. (6), including a description of how costs will be assessed
under sub. (8).
7. The address to
use in directing correspondence to the insurer or self-insurer regarding the
dispute.
8. That pursuant to s.
102.16(2m)
(b), Stats., once the notice required by this
subsection is received by a provider, the provider may not collect a fee for
the disputed treatment from, or bring an action for collection of the fee for
that disputed treatment against, the employee who received the
treatment.
(b) At the
request of an insurer or self-insurer, the department may extend the 60-day
period in par. (a) where the insurer or self-insurer is unable to obtain the
supporting medical documentation within the 60-day period, or where the
department determines other extraordinary circumstances justify an extension.
(c) Except as provided in par.
(b), if an insurer or self-insurer provides the notice after the 60-day period,
the provider may immediately request the department to issue a default order
requiring the insurer or self-insurer to pay the full amount in
dispute.
(4) NOTICE TO
THE INSURER OR SELF-INSURER. After receiving notice from the insurer or
self-insurer under sub. (3) and, except as provided in sub. (3) (b) and (c), at
least 30 days prior to submitting a dispute to the department, the provider
shall explain to the insurer or self-insurer in writing why the treatment was
necessary to cure and relieve the effects of the injury, including a diagnosis
of the condition for which treatment was provided.
(5) RESPONSE BY THE INSURER OR SELF-INSURER.
(a) Within 30 days from the date on which the
provider sent or delivered notice under sub. (4), an insurer or self-insurer
shall notify the provider whether or not it accepts the provider's explanation
regarding necessity of treatment.
(b) If the insurer or self-insurer accepts
the provider's explanation, the provider's fee must be paid in full, or in an
amount mutually agreed to by the provider and insurer or self-insurer, within
the 30-day period specified in par. (a). In the case of late payment, the
insurer or self-insurer shall pay simple interest on the amount mutually agreed
upon at the annual rate of 12 percent, from the day after the 30-day period
lapses to the date of actual payment to the provider.
(6) SUBMITTING DISPUTES TO THE DEPARTMENT.
(a) For the department to determine whether
or not treatment was necessary under s.
102.16(2m),
Stats., a provider shall, after the 30-day notice period in sub. (4) has
elapsed, apply to the department in writing to resolve the dispute. The
provider shall apply to the department within 9 months from the date it
receives notice under sub. (3) from the insurer or self-insurer refusing to pay
the provider's bill.
(b) The
provider's application to the department shall include copies of all
correspondence related to the dispute.
(c) At the time it files the application with
the department, the provider shall send or deliver to the insurer or
self-insurer which is refusing to pay for the treatment in dispute a copy of
all materials submitted to the department.
(d) When an application to resolve a dispute
is submitted, the department shall notify the insurer or self-insurer that it
has 20 days to either pay the bill in full for the treatment in dispute or to
file an answer under par. (e) for the department to use in the review process
in sub. (7).
(e) The answer shall
include copies of any prior correspondence relating to the dispute which the
provider has not already filed, and any other material which responds to the
provider's application. The answer shall include the name of the organization,
and credentials of any individual, whose review of the case has been relied
upon in reaching the decision to deny payment.
(f) The department may develop and require
the use of forms to facilitate the exchange of information.
Note: To obtain a form under par. (f), contact the Department of Workforce Development, Worker's Compensation Division, 201 East Washington Avenue, P.O. Box 7901, Madison, Wisconsin 53707 or access the form online at http://dwd.wisconsin.gov.
(7) REVIEW PROCESS.
(a) After the 20-day period in sub. (6) (d)
for the insurer or self-insurer to answer has passed, the department shall
provide a copy of all materials in its possession relating to a dispute to an
impartial health care services review organization, or to an expert from a
panel of experts established by the department, to obtain an expert written
opinion on the necessity of treatment in dispute.
(b) In all cases where the dispute involves a
Wisconsin provider, the expert reviewer shall be licensed to practice in
Wisconsin.
(c) When necessary to
provide a fair and informed decision, the expert may contact the provider,
insurer or self-insurer for clarification of issues raised in the written
materials. Where the contact is in writing, the expert shall provide all
parties to the dispute with a copy of the request for clarification and a copy
of any responses received. Where the contact is by phone, the expert shall
arrange a conference call giving all parties an opportunity to participate
simultaneously.
(d) Within 90 days
of receiving the material from the department under par. (a), the review
organization or panel shall provide the department with the expert's written
opinion regarding the necessity of treatment, including a recommendation
regarding how much of the provider's bill the insurer or self-insurer should
pay, if any. At the same time that it provides an opinion to the department,
the review organization or panel on which the expert serves shall send a copy
of the opinion to the provider and the insurer or self-insurer which are
parties to the dispute.
(e) The
provider, insurer or self-insurer shall have 30 days from the date the expert's
opinion is received by the department under par. (d) to present written
evidence to the department that the expert's opinion is in error. Unless the
department receives clear and convincing written evidence that the opinion is
in error, the department shall adopt the written opinion of the expert as the
department's determination on the issues covered in the written
opinion.
(f) If the necessity of
treatment dispute involves a claim for which an application for hearing is
filed under s.
102.17,
Stats., or an injury for which the insurer or self-insurer disputes the cause
of the injury, the extent of the disability, or other issues which could result
in an application for hearing being filed, the department may delay resolution
of the necessity of treatment dispute until a hearing is held or an order is
issued resolving the dispute between the injured employee and the insurer or
self-insurer.
(8)
PAYMENT OF COSTS.
(a) The department shall
charge the insurer or self-insurer the full cost of obtaining the written
opinion of the expert for the first dispute involving the necessity of
treatment rendered by an individual provider, unless the department determines
the provider's position in the dispute is frivolous or based on fraudulent
representations.
(b) In a
subsequent dispute involving the same provider, the department shall charge the
full cost of obtaining the expert's opinion to the losing party.
(c) Any time prior to the department's order
determining the necessity of treatment, the department shall dismiss the
application if the provider and insurer or self-insurer mutually agree on the
necessity of treatment and the payment of any costs incurred by the department
related to obtaining the expert opinion.
(9) DEPARTMENT INITIATIVE. In addition to the
provider's right to submit a dispute to the department under sub. (6), the
department may initiate resolution of a dispute on necessity of treatment when
requested to do so by an injured worker, an insurer or a self-insurer. The
department shall notify the insurer or self-insurer of its intention to
initiate the dispute resolution process and shall direct them to provide
information necessary to resolve the dispute. The department shall allow up to
60 days for the parties to respond, but may extend the response period at the
request of either party.
(10)
EXPERT PANELS. The department may establish one or more panels of experts in
one or more treating disciplines, and may set the terms and conditions for
membership on any panel. In making appointments to a panel the department shall
consider:
(a) An individual's training and
experience, including:
1. The number of years
of practice in a particular discipline;
2. The extent to which the individual
currently derives his or her income from an active practice in a particular
discipline; and,
3. Certification
by boards or other organizations;
(b) The recommendation of organizations that
regulate or promote professional standards in the discipline for which the
panel is being created; and,
(c)
Any other factors that the department may determine are relevant to an
individual's ability to serve fairly and impartially as a member of an expert
panel.
(11)
APPLICABILITY. This section first applies to health services provided on
January 1, 1992, and shall take effect on July 1, 1992.
Notes
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