Necessity of Treatment
The provider must file the dispute with the department within nine (9) months from the date they first received notice from the insurer or self-insured employer denying payment of the provider's bill. (Necessity of Treatment Dispute Resolution Request Form WKC-9380)
WC Treatment Guidelines
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.
Necessity of Treatment is in dispute:
- After receiving notice from the insurer or self-insurer that the treatment rendered to an injured worker is not necessary, at least 30 days prior to submitting a dispute to the department, 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 (DWD 80.73 (4)).
- 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 (DWD 80.73 (5a)). If accepted, 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 (DWD 80.73 (5b)).
- 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 (DWD 80.73 (6a)).
REQUEST FOR INDEPENDENT REVIEW (Letter GL92):
- 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.
- 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.
- For the first dispute filed by the provider, the cost of obtaining the written opinion by the expert will be charged to the insurer or self-insured employer. In all subsequent disputes filed by the same 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.
- 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.
REQUEST FOR DEFAULT ORDER: LATE NOTICE - OVER 60 DAYS (Guide Letter GL97):
- An insurer or self-insured employer shall provide written notice of the dispute to the health care provider within 60 days after receiving a bill that documents the treatment provided to the worker (DWD 80.73 (3a)). 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-insured 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.
NOTE: By law, when the provider files the dispute application with the department, the provider must, at the same time, send or deliver a copy of all materials submitted with the dispute application to the insurer or self-insured employer who is refusing to pay for the treatment it considers unnecessary.