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Health Cost Dispute FAQs

Ask the patient who their Worker’s Compensation Insurer, or third party administrator, is or who their employer contact person is for Worker’s Compensation. The best way for the provider to receive timely payment is to identify the worker’s compensation carrier or third party administrator for the patient’s employer. This should be done as soon as the patient calls for an appointment.

Contact the employer as soon as possible after the patient contacts you for treatment. Tell the employer who you are treating or planning to treat and find out who the responsible person is at the insurance carrier or third party administrator.

You can look up the insurer at WCRB Coverage Lookup by entering the name and location of the employer. You can also call 608-266-1340 and ask for the Bureau of Insurance to assist you.

Once you send a bill to the proper worker’s compensation insurer you are barred from billing the worker unless liability, or the extent of liability, is raised. If it is determined that there is no compensable injury under worker’s compensation, you may seek recovery of unpaid bills from the patient’s health insurer or the patient.

If the insurer has not contacted you within sixty days after you mailed your bill for services to them, you may initiate a necessity of treatment dispute resolution request, (Wis. Admin. Code § DWD 80.73), by submitting the necessity of treatment form WKC-9380. Please attach a copy of your bill and any documentation that you mailed to the insurance company.

We ask that you contact the payer and seek prompt payment of the amount ordered. If the payer does not pay in a timely manner, write the Department and ask for a certified copy of the order. The certified copy can be entered as a judgment in circuit court. You can address your request for a certified copy of the order to the attention of Lynn Brower.

You may also contact the Office of the Commissioner of Insurance (OCI) to file a formal complaint against the insurance carrier. OCI can be reached at 608-266-3585, or toll-free 800-236-8517, or by email to OCI Complaints.

You may initiate a reasonableness of fee dispute resolution request by submitting the reasonableness of fee form WKC-9498. Per Administrative Code § DWD 80.72(4)(d), the insurer, or self-insured, shall file an answer with the department within 20 days, and send a copy of the response to the provider.

Have the patient call our office, 608-266-1340 and request an application for hearing. An Administrative Law Judge can decide whether or not the claim was occupational. Some insurers may be willing to compromise the claim without the necessity of formal hearing.

The department may set aside, reverse or modify a determination 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 § 102.23, Wis. Stats.

If the necessity of treatment or the reasonableness of fee dispute involves a claim for which an application for hearing is filed under § 102.17, Wis. Stats., or an injury for which the insurer or self-insured 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 or reasonableness of fee dispute until a hearing is held or an order is issued resolving the dispute between the injured employee and the insurer or self-insured employer.

The provider can expect the Department to serve notice to the insurance carrier, or self-insured employer, and the provider within 90 days of receiving the dispute application from the provider. Typically, a provider may expect a reasonableness of fee or a necessity of treatment dispute application to be resolved within 90 days from the date of the Department’s notice. In some cases, disputes may take additional time to resolve.

The Worker's Compensation Treatment Guidelines in ch. DWD 81 of the Wisconsin Administrative Code were created and are to be used for one very limited purpose. The Treatment Guidelines are factors for an impartial health care services review organization or a member from an independent panel of experts to consider in rendering opinions to resolve necessity of treatment disputes between health care providers and insurance carriers or self-insured employer under s. 102.16 (2m), Wis. Stats., and s. DWD 80.73 of the Wisconsin Administrative Code.

There is no statutory authority allowing the use of the Treatment Guidelines for utilization of treatment reviews to deny treatment outside of the necessity of treatment dispute resolution process. Any action by an insurance carrier or self-insured employer to deny treatment solely based on the Treatment Guidelines in ch. DWD 81 of the Wisconsin Administrative Code, and not through the necessity of treatment dispute process, cannot be enforced or upheld under the Wisconsin Worker's Compensation Act.

Due to the ever-changing and expansive world of health care, not every health care service is covered in these guidelines. The absence of a health care service in the Treatment Guidelines should not be interpreted as meaning that the treatment is not compensable. Under s. 102.42 (1), Wis. Stats., the employer and insurance carrier are liable for necessary treatment reasonably required to cure and relieve the employee from the effects of a work injury. This obligation continues as required to prevent further deterioration in the condition of the employee or to maintain the existing status of the condition whether or not the employee has reached an end of healing.

Chapter DWD 81: Worker's Compensation Treatment Guidelines