102.16 Submission of disputes, contributions by employees.
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102.16 Submission of disputes, contributions by employees.
(a)Any controversy concerning compensation or a violation of sub.
(3), including a controversy in which the state may be a party, shall be submitted to the department in the manner and with the effect provided in this chapter.
(b)A compromise of any claim for compensation may be reviewed and set aside, modified, or confirmed by the department within one year after the date on which the compromise is filed with the department, the date on which an award has been entered based on the compromise, or the date on which an application for the department to take any of those actions is filed with the department.
(d)Unless the word “compromise” appears in a stipulation of settlement, the settlement shall not be considered a compromise, and further claim is not barred except as provided in s. 102.17
(4)regardless of whether an award is made. The employer, insurer, or dependent under s. 102.51
(5)shall have equal rights with the employee to have a compromise or any other stipulation of settlement reviewed under this subsection. Upon petition filed with the department under this subsection, the department may set aside the award or otherwise determine the rights of the parties.
(e)A payment pursuant to a compromise agreement, including the full amount of any lump sum payment, may be made directly to the employee and need not be paid into an account at a credit union, savings bank, savings and loan association, bank, or trust company.
(a)If an insurer or self-insured employer concedes by compromise under sub.
(1)or stipulation under s. 102.18
(a)that the insurer or self-insured employer is liable under this chapter for any health services provided to an injured employee by a health service provider, but disputes the reasonableness of the fee charged by the health service provider, the department may include in its order confirming the compromise or stipulation a determination made by the department under sub.
(2)as to the reasonableness of the fee or, if such a determination has not yet been made, the department may notify, or direct the insurer or self-insured employer to notify, the health service provider under sub.
(b)that the reasonableness of the fee is in dispute. The department shall deny payment of a health service fee that the department determines under sub.
(2)to be unreasonable. A health service provider and an insurer or self-insured employer that are parties to a fee dispute under this paragraph are bound by the department’s determination under sub.
(2)on the reasonableness of the disputed fee, unless that determination is set aside, reversed, or modified by the department under sub.
(f)or is set aside on judicial review as provided in sub.
(f).
Effective date note NOTE: Par.
(a)is amended by 2025 Wis. Act 15 eff. on the day after the notice from the department of health services under 2025 Wis. Act 15 s. 9119
(b)1 . is published by the legislative reference bureau in the Wisconsin Administrative Register, except that, if the notice is not published before 8-1-27, the treatment of par.
(a)by 2025 Wis. Act 15 is void. As amended by 2025 Wis. Act 15 , par.
(a)reads:
Effective date text
(a)If an insurer or self-insured employer concedes by compromise under sub.
(1)or stipulation under s. 102.18
(a)that the insurer or self-insured employer is liable under this chapter for any health services provided to an injured employee by a health service provider, but disputes the fee charged by the health service provider, the department may include in its order confirming the compromise or stipulation a determination made by the department under sub.
(2)as to the fee or, if such a determination has not yet been made, the department may notify, or direct the insurer or self-insured employer to notify, the health service provider under sub.
(b)that the fee is in dispute. The department shall deny payment of a health service fee that the department determines is unreasonable or not allowable under sub. (2). A health service provider and an insurer or self-insured employer that are parties to a fee dispute under this paragraph are bound by the department’s determination under sub.
(2)on the fee, unless that determination is set aside, reversed, or modified by the department under sub.
(f)or is set aside on judicial review as provided in sub.
(2)(f).
(b)If an insurer or self-insured employer concedes by compromise under sub.
(1)or stipulation under s. 102.18
(a)that the insurer or self-insured employer is liable under this chapter for any treatment provided to an injured employee by a health service provider, but disputes the necessity of the treatment, the department may include in its order confirming the compromise or stipulation a determination made by the department under sub.
(2m)as to the necessity of the treatment or, if such a determination has not yet been made, the department may notify, or direct the insurer or self-insured employer to notify, the health service provider under sub.
(b)that the necessity of the treatment is in dispute. Before determining under sub.
(2m)the necessity of treatment provided to an injured employee, the department may, but is not required to, obtain the opinion of an expert selected by the department who is qualified as provided in sub.
(c). The standards promulgated under sub.
(g)shall be applied by an expert and by the department in rendering an opinion as to, and in determining, necessity of treatment under this paragraph. In cases in which no standards promulgated under sub.
(g)apply, the department shall find the facts regarding necessity of treatment. The department shall deny payment for any treatment that the department determines under sub.
(2m)to be unnecessary. A health service provider and an insurer or self-insured employer that are parties to a dispute under this paragraph over the necessity of treatment are bound by the department’s determination under sub.
(2m)on the necessity of the disputed treatment, unless that determination is set aside, reversed, or modified by the department under sub.
(e)or is set aside on judicial review as provided in sub.
(e).
(c)If an insurer or self-insured employer concedes by compromise under sub.
(1)or stipulation under s. 102.18
(a)that the insurer or self-insured employer is liable under this chapter for the cost of a prescription drug dispensed under s. 102.425
(2)for outpatient use by an injured employee, but disputes the reasonableness of the amount charged for the prescription drug, the department may include in its order confirming the compromise or stipulation a determination made by the department under s. 102.425
(4m)as to the reasonableness of the prescription drug charge or, if such a determination has not yet been made, the department may notify, or direct the insurer or self-insured employer to notify, the pharmacist or practitioner dispensing the prescription drug under s. 102.425
(b)that the reasonableness of the prescription drug charge is in dispute. The department shall deny payment of a prescription drug charge that the department determines under s. 102.425
(4m)to be unreasonable. A pharmacist or practitioner and an insurer or self-insured employer that are parties to a dispute under this paragraph over the reasonableness of a prescription drug charge are bound by the department’s determination under s. 102.425
(4m)on the reasonableness of the disputed prescription drug charge, unless that determination is set aside, reversed, or modified by the department under s. 102.425
(e)or is set aside on judicial review as provided in s. 102.425
(e).
(a)Except as provided in this paragraph, the department has jurisdiction under this subsection, sub.
(a), and s. 102.17 to resolve a dispute between a health service provider and an insurer or self-insured employer over the reasonableness of a fee charged by the health service provider for health services provided to an injured employee who claims benefits under this chapter. A health service provider may not submit a fee dispute to the department under this subsection before all treatment by the health service provider of the employee’s injury has ended if the amount in controversy, whether based on a single charge or a combination of charges for one or more days of service, is less than $25. After all treatment by a health service provider of an employee’s injury has ended, the health service provider may submit any fee dispute to the department, regardless of the amount in controversy. The department shall deny payment of a health service fee that the department determines under this subsection to be unreasonable.
(am)A health service provider and an insurer or self-insured employer that are parties to a fee dispute under this subsection are bound by the department’s determination under this subsection on the reasonableness of the disputed fee, unless that determination is set aside on judicial review as provided in par.
(f).
(b)An insurer or self-insured employer that disputes the reasonableness of a fee charged by a health service provider or the department under sub.
(a)or s. 102.18
(bg)1. shall provide reasonable written notice to the health service provider that the fee is being disputed. After receiving reasonable written notice under this paragraph or under sub.
(a)or s. 102.18
(bg)1. that a health service fee is being disputed, a health service provider may not collect the disputed fee from, or bring an action for collection of the disputed fee against, the employee who received the services for which the fee was charged.
(c)After a fee dispute is submitted to the department, the insurer or self-insured employer that is a party to the dispute shall provide to the department information on that fee and information on fees charged by other health service providers for comparable services. The insurer or self-insured employer shall obtain the information on comparable fees from a database that is certified by the department under par.
(h). Except as provided in par.
(e)1. , if the insurer or self-insured employer does not provide the information required under this paragraph, the department shall determine that the disputed fee is reasonable and order that it be paid. If the insurer or self-insured employer provides the information required under this paragraph, the department shall use that information to determine the reasonableness of the disputed fee.
Effective date note NOTE: Par.
(c)is affected by 2025 Wis. Act 15 eff. on the day after the notice from the department of health services under 2025 Wis. Act 15 s. 9119
(b)1 . is published by the legislative reference bureau in the Wisconsin Administrative Register, except that, if the notice is not published before August 1, 2027, the treatment of par.
(c)is void. As affected, par.
(c)reads:
Effective date text
(c)1. Except as provided in subd. 2., after a fee dispute is submitted to the department, the insurer or self-insured employer that is a party to the dispute shall provide to the department information on that fee and information on fees charged by other health service providers for comparable services. The insurer or self-insured employer shall obtain the information on comparable fees from a database that is certified by the department under par.
(h)2. Except as provided in par.
(e)1., if the insurer or self-insured employer does not provide the information required under this subdivision, the department shall determine that the disputed fee is reasonable and order that it be paid. If the insurer or self-insured employer provides the information required under this subdivision, the department shall use that information to determine the reasonableness of the disputed fee under par. (d).
Effective date text 2. After a dispute is submitted to the department concerning the applicability of s. 102.423 to the fee or the amount of the fee under s. 102.423, the insurer or self-insured employer that is a party to the dispute shall provide to the department information on that fee, information on the medical records and bill provided to the insurer or self-insured employer in connection with that fee, and any other information requested by the department. If the insurer or self-insured employer does not provide the information required under this subdivision to confirm the applicability of s. 102.423, the department shall determine that s. 102.423 does not apply to the fee and may adjudicate the fee under subd. 1.
If the insurer or self-insured employer does not provide the information required under this subdivision to determine that the amount of the fee exceeds the allowable amount under s. 102.423, as applicable, the department shall determine that the disputed fee is allowable and order that it be paid. If the insurer or self-insured employer provides the information required under this subdivision, the department shall use that information to determine if s. 102.423 applies to the disputed fee and whether the amount of the fee otherwise comports with s. 102.423.
(d)The department shall analyze the information provided to the department under par.
(c)according to the criteria provided in this paragraph to determine the reasonableness of the disputed fee. Except as provided in 2011 Wisconsin Act 183 , section 30
(b), the department shall determine that a disputed fee is reasonable and order that the disputed fee be paid if that fee is at or below the mean fee for the health service procedure for which the disputed fee was charged, plus 1.2 standard deviations from that mean, as shown by data from a database that is certified by the department under par.
(h). Except as provided in 2011 Wisconsin Act 183 , section 30
(b), the department shall determine that a disputed fee is unreasonable and order that a reasonable fee be paid if the disputed fee is above the mean fee for the health service procedure for which the disputed fee was charged, plus 1.2 standard deviations from that mean, as shown by data from a database that is certified by the department under par.
(h), unless the health service provider proves to the satisfaction of the department that a higher fee is justified because the service provided in the disputed case was more difficult or more complicated to provide than in the usual case.
Effective date note NOTE: Par.
(d)is affected by 2025 Wis. Act 15 eff. on the day after the notice from the department of health services under 2025 Wis. Act 15 s. 9119
(b)1 . is published by the legislative reference bureau in the Wisconsin Administrative Register, except that, if the notice is not published before August 1, 2027, the treatment of par.
(d)is void. As affected, par.
(d)reads: