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Necessity of Treatment
Necessity of treatment
provisions can be found in section 102.16 (2m) of the Wisconsin state
statutes and are further detailed in DWD Administrative Code, section 80.73
When there is a dispute
between a health care provider and an insurer or self-insured employer
regarding the necessity of treatment provided to an injured worker, the
provider may request the department resolve the dispute. The Department
will than obtain and adopt the opinion of an independent medical expert in
the same profession.
The cost of the first
dispute filed by the provider will be charged to the insurer or
self-insured employer. In all subsequent disputes filed by the provider,
the losing party will be charged the full cost. The provider is prohibited
from collecting the fee from the employee after being notified that the
necessity of the treatment is in dispute.
An insurer or
self-insured employer that disputes the necessity of treatment provided by
a health service provider or the department shall provide reasonable
notice to the health service provider that the necessity of that treatment
is being disputed. After receiving reasonable notice that the necessity of
treatment is being disputed, a health service provider may not collect a
fee for that disputed treatment from, or bring an action for collection of
the fee for that disputed treatment against, the employee who received the
treatment.
Before determining the
necessity of treatment provided for an injured employee, the department
shall obtain a written opinion on the necessity of the treatment in
dispute from an expert selected by the department. To qualify as an
expert, a person must be licensed to practice the same health care
profession as the individual health service provider whose treatment is
under review and must either be performing services for an impartial
health care services review organization or be a member of an independent
panel of experts established by the department. The department shall adopt
the written opinion of the expert as the department's determination on the
issues covered in the written opinion, unless the health service provider
or the insurer or self-insured employer present clear and convincing
written evidence that the expert's opinion is in error.
The department may set
aside, reverse or modify a determination under this subsection within 30
days after the date of the determination. The Department may set aside,
reverse or modify a determination within 60 days on grounds of
mistake. A health service provider,
insurer or self-insured employer that is aggrieved by a determination of
the department under this subsection may seek judicial review of that
determination in the same manner that compensation claims are reviewed
under s. 102.23.
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NOTICE TO THE PROVIDER
The insurer or self-insurer who refused to pay for treatment rendered
to an injured worker because it disputes
that any treatment is necessary or in a case
where liability or the extent of liability is an issue, is required to give the
provider written notice of payment denial within 60 days of receiving a bill. The notice shall specify:
- The name of the
patient-employee;
- The name of the
employer on the date of injury;
- The date of the
treatment in dispute;
- The amount charged
for the treatment and the amount in dispute;
- 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;
- The provider's right
to initiate an independent review by the department within 9 months,
including a description of how the costs for the review will be assessed;
- The address to use
in directing correspondence to the insurer or self-insurer regarding the
dispute; and
- 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.
If an insurer or
self-insurer provides the notice after the 60-day period, or after 60 days
the provider has not received a reply from the insurer or self-insurer, 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. No dispute
shall be submitted to the department for resolution if the dispute is less
than $25.00 and treatment with the provider is ongoing.
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NOTICE TO THE INSURER OR
SELF-INSURER
After
receiving notice from the insurer or self-insurer, 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.
RESPONSE BY THE INSURER OR
SELF-INSURER
- Within
30 days from the date on which the provider sent or delivered
notice, an insurer or self-insurer shall notify the provider whether or
not it accepts the provider's explanation regarding necessity of
treatment.
- 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).
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SUBMITTING DISPUTES TO THE
DEPARTMENT
- For the department to
determine whether or not treatment was necessary a provider shall, after
the 30-day notice period has elapsed, apply to the department in writing
to resolve the dispute. (Necessity of
Treatment Dispute Resolution Request Form WKC-9380) The provider shall apply to
the department within 9 months from the date it receives notice from the
insurer or self-insurer refusing to pay the provider's bill.
- The provider's
application to the department shall include copies of all correspondence
related to the dispute.
- 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.
- 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.
- The answer shall
include copies of any prior correspondence relating to the dispute, which
the provider has not already filed, and any other material that 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 denying payment.
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REVIEW PROCESS
- After the 20-day
period 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.
- In all cases where
the dispute involves a Wisconsin provider, the expert reviewer shall be
licensed to practice in Wisconsin.
- 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.
- Within 90 days of
receiving the material from the department 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.
- The provider, insurer
or self-insurer shall have 30 days from the date the expert's opinion is
received by the department 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.
- 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.
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