102.423 Health service fee schedule.

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A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

(1)Definitions. In this section:

(a)“Eligible hospital” has the meaning given under s. 50.38

(1).

(b)“Items or services” means hospital facility services that are “items and services,” as defined under 45 CFR 180.20 .

(2)Applicability.

(a)Subject to par.

(b), this section shall apply to a fee for an item or service only if all of the following apply:

1. The fee is for an item or service that was provided by an eligible hospital.

2. The fee is for an item or service for which the eligible hospital may receive hospital inpatient or hospital outpatient reimbursement from the Medical Assistance program under subch. IV of ch. 49 .

3. The fee was paid within the applicable period under par.

(c).

a. If a notice from the department of health services under s. 50.38

(a)1. is published by the legislative reference bureau in the Wisconsin Administrative Register indicating that either s. 50.38

(a)1. a. or b. applies, then this section shall not apply from the day the notice is published until subd. 2. applies.

b. Except as provided in subd. 1. a. , if a notice from the department of health services under s. 50.38

(a)1. is published by the legislative reference bureau in the Wisconsin Administrative Register indicating that either s. 50.38

(a)1. c. or d. applies, then this section shall not apply beginning on the first day of the calendar year following the calendar year in which the notice is published until subd. 2. applies.

a. Notwithstanding subd. 1. , if a notice from the department of health services under s. 50.38

(b)1. is published by the legislative reference bureau in the Wisconsin Administrative Register indicating that either s. 50.38

(b)1. a. or b. applies, then this section applies from the day the notice is published.

b. Notwithstanding subd. 1. and except as provided in subd. 2. a. , if a notice from the department of health services under s. 50.38

(b)1. is published by the legislative reference bureau in the Wisconsin Administrative Register indicating that either s. 50.38

(b)1. c. or d. applies, then this section applies beginning on the first day of the calendar year following the calendar year in which the notice is published.

1. In order for this section to apply to a fee, an insurer or self-insured employer must remit payment for the fee to the eligible hospital within the period specified in subd. 2. , which shall begin to run on the day after whichever of the following dates is latest:

a. The date the eligible hospital electronically sends to the insurer or self-insured employer the medical records to substantiate the submitted hospital bill or, if such records are sent by mail, the 3rd day after the date the records are postmarked.

b. The date the eligible hospital electronically sends the bill described in subd. 1. a. or, if the bill is sent by mail, the 3rd day after the date the bill is postmarked.

a. If the aggregate amount billed is equal to or greater than $65,000, the period within which an insurer or self-insured employer must remit payment shall be 90 calendar days after the date determined under subd. 1.

b. If the aggregate amount billed is less than $65,000, the period within which an insurer or self-insured employer must remit payment shall be 60 calendar days after the date determined under subd. 1.

3. An insurer or self-insured employer may request that an eligible hospital send additional medical records to the insurer or self-insured employer that the insurer or self-insured employer reasonably believes are necessary to substantiate the claim. The eligible hospital shall provide the requested records to the extent practicable or within 10 days after the request is received, but a request under this subdivision by an insurer or self-insured employer shall not operate to extend the period specified under subd. 2. a. or b.

a. An insurer or self-insured employer may submit a request to the department for an extension to the period specified in subd. 2. if the insurer or self-insured employer has not yet determined whether an injury is compensable under this chapter. The department may, pursuant to rules promulgated under subd. 4. e. , authorize such an extension if the department determines that the insurer or self-insured employer has not yet determined compensability despite its good faith effort to do so.

A single extension granted by the department shall not exceed 30 calendar days. There is no limit to the number of extensions that an insurer or self-insured employer may request or that the department may grant under this subdivision, but an insurer or self-insured employer may not request another extension after a denial.

b. If the department denies a request for extension under this subdivision, the insurer or self-insured employer shall, notwithstanding subds. 1. and 2. , have 14 calendar days after the denial to remit payment for the fee to the eligible hospital. If the insurer or self-insured employer remits payment for the fee to the eligible hospital within that 14-day period, then this section applies to that fee.

c. A request by an insurer or self-insured employer for an extension under this subdivision or a denial by the department of a request for extension under this subdivision shall not be used as evidence of bad faith by the insurer or self-insured employer.

d. Any information provided by an insurer or self-insured employer pursuant to this subdivision shall not be used as evidence of bad faith by the insurer or self-insured employer.

e. The department shall promulgate rules specifying requirements and procedures for requesting and granting extensions under this subdivision. The rules shall specify requirements or procedures to ensure that notice is provided to an eligible hospital when a request is made under this subdivision.

(3)Establishment of schedule.

(a)By July 1, 2027, the department shall establish a schedule of the maximum fees that the eligible hospital may charge an insurer or self-insured employer for an item or service provided to an injured employee who claims benefits under this chapter. When the schedule under this subsection is established, the department shall send a notice to the legislative reference bureau for publication in the Wisconsin Administrative Register of the date that the schedule will be effective, which shall be no earlier than the date the notice is published. In determining the maximum fees, the department shall divide the state into 5 regions based on geographical and economic similarity, including similarity in the cost of items and services, and, for each region, shall do all of the following:

a. Determine, for each item or service included in the schedule, the amount that represents the 75th percentile of the commercial, in-network negotiated amounts, across all commercial health insurance plans, issuers, and administrators in that region. The department shall make the determinations under this subd. 1. a. in accordance with subd. 1. b. and c.

b. In order to determine the amounts under this subdivision, the department shall utilize the machine-readable files of all health insurance plans, issuers, administrators, and hospitals made public pursuant to 26 CFR 54.9815-2715 A3, 29 CFR 2590.715-2715 A3, 45 CFR 147.212 , and 45 CFR 180.40

(a)that contain in-network negotiated rates for each eligible hospital in that region.

c. In determining the amounts under this subdivision, the department shall not use any amounts from Medicare advantage, services provided under a managed care system under the Medical Assistance program under subch. IV of ch. 49 , databases certified by the department under s. 102.16

(h), or any sources other than those specified in subd. 1. b.

2. Set the maximum fee for each item or service included in the schedule at 120 percent of the amount determined under subd. 1. for that region.

(am)The department shall contract with a 3rd party to perform the duties specified under pars.

(a)1. and 2.

(b)Every year, the department shall redetermine the schedule of maximum fees using the procedures specified in par.

(a), subject to par.

(am).

(d)The department shall publish the current fee schedule established under this subsection on the department’s website. Notwithstanding s. 227.10

(1), the fee schedule need not be promulgated as a rule.

(4)Liability of insurer or self-insured employer.

(a)The liability of an insurer or self-insured employer for an item or service included in a fee schedule established under sub.

(3)is limited to the maximum fee allowed under the schedule for the item or service as of the date on which the item or service was provided, any fee agreed to by contract between the insurer or self-insured employer and eligible hospital for the item or service as of that date, or the eligible hospital’s actual fee for the item or service as of that date, whichever is least.

(b)An eligible hospital that provides items or services to an injured employee under this chapter may not collect, or bring an action to collect, from the injured employee any charge that is in excess of the liability of the insurer or self-insured employer under this subsection.

(c)A schedule of maximum fees established under sub.

(3)first applies to an item or service provided to an injured employee on the effective date specified in the notice published under sub.

(a).

(d)Payment of a claim pursuant to this section is not an admission of causality or responsibility with respect to any future payments or obligations.

(5)Rules. The department shall, subject to sub.

(d), promulgate rules to implement this section.

Effective date note NOTE: This section is created 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 this section is void.