Website - Division of Worker's Compensation
Email - WC Administration
Website - Division of Worker's Compensation
Email - WC Administration
Members present: Mr. Beiriger, Mr. Brand, Mr. Buchen, Mr. Collingwood, Ms. Connor (for Mr. Scott), Ms. Huntley-Cooper, Mr. Kent, Ms. Nugent, Mr. Olson, Ms. Pehler, Mr. Redman, Ms. Vetter
Excused: Mr. Newby
Absent: Mr. Schwanda
Staff present: Mr. Aiello, Mr. Conway, Mr. O’Malley, Ms. Knutson, and Mr. Krueger
Mr. Conway indicated there have been some discussions with the Division of Vocational Rehabilitation (DVR) concerning the federal requirement to look at comparable benefits available to pay costs associated with retraining. If comparable benefits are available DVR can not pay those costs (e.g. tuition, fees and books). It is DVR’s position the insurance carrier should be paying those costs. The WCD will invite a representative from DVR to appear and explain their position.
Mr. O’Malley explained the Department proposals summarized in the handout:
1. §102.31(2)(a) The WCRB will require the insurance company to provide
notice of cancellation, termination and non-renewal by electronic means
only. The majority of notices are already provided electronically. Mr.
Krueger explained that the requirement will be phased in by the WCRB over
two years and the insurers are already aware of it.
2. §102.31(3) The current statute does not contain any language regarding recommending enforcement proceedings to the Office of Commissioner of Insurance (OCI) for failure to answer correspondence or failure to allow the department to examine an insurer’s books and records.
3. §102.475(4m)(b) Clarifies that written notice of a dispute regarding reasonableness of pharmacy charges must be provided by an insurer.
4. §102.44(5) Since July 1, 1980, the WCD has interpreted the Social Security reverse offset to not apply to vocational rehabilitation retraining benefits (TTD). The proposed language will reverse the Court of Appeals decision in Michels Pipeline Construction v. LIRC, 309 Wis.2d 470 (Ct. App. 2008) and codify the WCD’s longstanding interpretation.
5. §102.60(1m) & (6) This amendment eliminates the requirement that the employer pay the injured minor additional compensation for wage loss. The changes which took affect 4/1/06 provided that the child labor penalties were payable to the Work Injury Supplemental Benefit Fund rather than to the injured minor. However, s. 102.60(6) stating that the injured minor could not sustain a wage loss was left in the statute. The WCD anticipates that this may create a problem because the language could be interpreted that a wage loss would continue to minors after the three-day waiting period.
6. §102.64(32) The department may contract with the department of administration or a third party administrator (TPA) to handle claims involving the Work Injury Supplemental Benefit Fund (WISBF). Further, that a TPA may retain the services of a private attorney to defend the WISBF and charges for services shall be paid from the WISBF. Currently the Department of Justice paralegals handle the claims adjustment function in these cases. With budget reductions, the DOJ is limited in the number of staff that are devoted to these functions.
7. §102.75(2) Interest on surcharges accrues if the surcharges are not paid within 90 days. The proposed amendment decreases that time to 30 days to synchronize payments with the State’s accounting system. The computer system is not set up to handle 90-day payments.
8. §102.82(2)(ar) The proposed amendment concerns the assessment against illegally uninsured employers and provides that the department may waive any payments owed by the uninsured employer for any benefits paid by the UEF when the department determines the employer was a victim of fraud, misrepresentation or gross negligence by an insurance agent or broker. In practice, OCI would make a determination that the employer was a victim of fraud. The DOJ would pursue collection against the agent or broker.
9. & 10. DWD 80.61 relating to wrap-up insurance policies. The amendments would delete reference to an obsolete form number.
11. DWD 80.65 relating to notice of termination, non-renewal or cancellation. This rule amendment cross-references §102.31(2)(a) and provides that notice be submitted electronically in a medium approved by the department.
12 &13. DWD 80.72 pertaining to reasonableness of fees. The amendment provides that the employer or insurer shall provide a copy of the bill reviewer report with the notice to the health care provider that the medical bill is being reduced. Providing this information earlier in the process should assist in quicker resolution of reasonableness of fee disputes. In addition, the amendment deletes reference to the DRG coding system for Medicare charges. Medicare charges are making their way in to reasonableness of fee disputes. This language should help clarify that data for resolving fee disputes includes billed charges and does not include Medicate charges.
14. DWD 80.73 pertaining to necessity of treatment. This amendment provides the insurer or self-insurer shall provide a copy of the reviewing doctor’s report to the provider when providing notice that the medical treatment is denied as not medically necessary. Providing this information earlier in the process should assist in quicker resolution of necessity of treatment disputes.
Ms. Knutson indicated the number of health cost disputes filed and the complexity of the coding/data issues has significantly increased in the past few years. Carriers are challenging the medical coding by the providers and defending fee reductions on theories involving data that is not provided or is not verifiable as meeting the reliable and relevant standards. Rather than just addressing “outliers” the carriers are attempting to reduce all bills. In addition, some providers have significantly increased charges for various billing codes that do not have certified database values. The statute and administrative rules were first enacted 16 years ago with very few amendments over the years and they should be reviewed for more global changes/updating.
Mr. O’Malley indicated the WCD may have a few more proposals. The WCD is watching the court appeals involving the constitutionality of the statutory amendments to §102.17(4) enacted effective April 1, 2006 relating to payment of traumatic barred claims. A circuit court in Fond du Lac County found the statute unconstitutional. The Attorney General’s Office represents the WISBF on appeal and it is their opinion that if the statute is found unconstitutional, there may be a statutory “gap” and the continuing benefits for barred traumatic claims may not revert back to the WISBF.
The department is considering formally codifying the COR process in an administrative rule which would include the same conditions, principles and practices currently implemented. Ms. Vetter commented that the process is still relatively new and the department should take some time and make sure it continues working as expected before codifying the process.
Mr. O’Malley also indicated the Health Care Provider Advisory Committee may have some proposed amendments to DWD Chap. 81.
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