Appropriate Use of Certified Health Cost Fee Databases to Help Resolve Fee Disputes

August 12, 1996

To: All Insurance Carriers and Self Insured Employers

From: Gregory Krohm, Administrator

This letter is a reminder about the appropriate use of certified health cost fee databases to help resolve fee disputes.

The Wisconsin Department of Workforce Development has certified seven proprietary databases under Wis. Admin. Code section DWD 80.72 (changed from Ind. 80.72 to DWD 80.72 effective July 1, 1996) for purposes of expediting fee disputes under s. 102.16(2) of the Wisconsin Statutes. Certified databases can be purchased from any of the seven database providers (listing enclosed). It also has certified a statewide hospital radiology database in the public domain which can be accessed and downloaded (downloading instructions enclosed) from the DWD Bulletin Board. The file names are HRDB9607.TXT for the July, 1996 file and HRDB9601.TXT for the January, 1996 file.

These data bases include CPT, HCPCS, DRG and ICD-9-CM coding schemes. They are updated twice a year effective prospectively for a six-month period every January 1 and July 1. The only amounts certified within these data bases are those based on at least 25 observations within the specified region of service. Where there are fewer than 25 observations supporting a specific code in a designated region, the data may be helpful in determining a reasonable amount of reimbursement, but it is not controlling and not to be represented as a certified amount. If a dispute is submitted to the Division based on fewer than 25 observations, the Division may combine averages from all the data bases to accumulate 25 or more observations and arrive at a reasonable amount for an order to resolve the dispute.

In instances where carriers and self-insured employers use certified databases to support reductions of reimbursement for medical service charges for worker's compensation purposes, a statement (sample enclosed) must be used to explain reductions to medical service providers.

The Workers' Compensation Division is also working with carriers, employers and medical providers to reduce the number of formal disputes. In 1995, small disputes of less than $10 accounted for nearly 1000 disputes, almost one third of all disputes submitted. The Division urges informal resolution of all disputes, especially those consisting of small dollar amounts. The Division is making a similar effort to communicate with medical providers in this matter. While the dispute process does work, we believe efforts of everyone to reduce formal disputes and concentrate efforts on the more substantive issues is in everyone's interests.

CERTIFIED DATA BASES OF
HEALTH SERVICE FEES FOR WISCONSIN

(Revised 7/15/96)

THE EMPLOYER HEALTH CARE ALLIANCE
COOPERATIVE (ALLIANCE)
37 KESSEL COURT
PO BOX 44365
MADISON WI 53744-4365
Contact: GLORIA NOLAN
Phone:608-276-6620
Fax: 608-276-6626

MEDIRISK INC
TWO PIEDMONT CENTER STE 400
3565 PIEDMONT ROAD
ATLANTA GA 30305-1502
Contact: CHRIS ANDERSON
Phone:404-364-6700 EXT. 3215
Fax: 404-364-6710

HEALTH INSURANCE ASSOC OF AMERICA (HIAA)
PREVAILING HEALTH CARE CHARGES SYSTEM
555 13TH ST N W #600 EAST
WASHINGTON DC 20004-1109
Contact: VICKIE HAUSEY
Phone:202-824-1600 EXT. 1687
Fax: 202-824-1800

MEDICAL DATA RESEARCH (MDR)
5225 WILEY POST WAY STE 500
SALT LAKE CITY UT 84116
Contact: KAREN BECKSTEAD
Phone:801-536-1100
Fax: 801-536-1009

MERIDIAN RESOURCE CORP
401 WEST MICHIGAN ST
MILWAUKEE WI 53201
Contact: MICHAEL OBLETZ
Phone:414-226-5212
Fax: 414-226-5798

MIDWEST COMP REVIEW SERVICE (MCRS)
PO BOX 81365
RACINE WI 53408
Contact: GLEN BOYLE
Phone:414-554-0886
Fax: 414-554-0573

WISCONSIN PHYSICIANS SERVICE INS CORP (WPS)
PO BOX 8190
MADISON WI 53708-8190
Contact: RICHARD DARGA
Phone:608-221-4711 ext. 3682
Fax: 608-223-3625

STATE OF WISCONSIN - HOSPITAL RADIOLOGY ONLY
PO BOX 7946
MADISON WI 53707
On this Web Site-- Return to the WC Home Page
608-264-6813 DWD on-line electronic bulletin board - modem call only
608-267-4438 Bulletin Board help line
Worker's Comp. Contact for Database Information:

Lee Shorey, shorel@mail.state.wi.us

Downloading Files from a Bulletin Board and File Transfer Protocols

HOW TO DOWNLOAD A FILE
Downloading is easy if you know a few basics. Files are transferred using a particular transfer protocol and you must tell your communications program what protocol the board is using for the transfer and what the name of the file is. You should also have previously told your program where to put the file, i.e., the default DOWNLOAD DIRECTORY (Do this in Procomm Plus with Alt-S, F, C).

Type D for Download.
Enter file name including the extension if any (blank extension is assumed if none is entered).
When the board is ready to send, hit Page Down (in DOS Procomm, Telix, and Qmodem and others) or Transfer/Receive (in most Windows apps). Then you may have to specify the transfer protocol which must the same as the board is telling you is being used...be careful here because sometimes the name of the protocol is somewhat different on this board from your software.
Enter the name of the file (or your software may pick it up from the screen).
Hit Enter to start the transfer. You will be told at the completion if there was a successful transfer. Don't worry about seeing an occasional error message during the transfer....those are blocks that are re-sent until received correctly.

FILE TRANSFER PROTOCOLS
The T command can be used to select a new protocol or to view the protocol you have currently selected. Protocol is the "language" that the Bulletin Board uses to communicate with your communications program. Several may be used but both must be using the same protocol.

If in doubt about which protocol to use, select Xmodem or Xmodem CRC. It's one of the slowest but all communication programs support it. When you are comfortable in downloading, try one of the faster protocols such as Ymodem (also called 1K-Xmodem) or Ymodem-Batch. The fastest protocol if you have an error-correcting modem is Ymodem-G (aka 1K-Xmodem-G) or Ymodem-G-Batch. Almost as fast and less subject to aborts is Zmodem and this is the recommended protocol if your program supports it. Ascii protocol may be used to download text files only (not EXE or ZIP files) but is the slowest protocol.

If your communications program supports it, we recommend using Zmodem as your protocol for all transfers.

STATE OF WISCONSIN - HOSPITAL RADIOLOGY DATABASE ONLY
PO BOX 7946
MADISON WI 53707
On this Web Site-- Return to the WC Home Page
608-264-6813 DWD on-line electronic bulletin board - modem call only
608-267-4438 Bulletin Board help line (voice)
Worker's Comp. Contact for Database Information:

Lee Shorey, shorel@mail.state.wi.us

SAMPLE HEALTH COST FEE DATABASE STATEMENT

HEALTH COST FEE DATA BASE STATEMENT

This statement is to provide written notice to health care providers as required under Wis. Admin. Code section DWD 80.72(3)(a) (formerly, IND 80.72)

____ The reimbursement rate for the treatment provided is based on a (name of database) database amount certified by the Department of Workforce Development.

OR

____ The reimbursement rate is not based on a formula amount certified by the Department of Workforce Development. Under Wisconsin's

Worker's Compensation law, when a database does not contain a certified formula amount for the health service procedure which is the subject of a fee dispute, the Department may use other information that the Department considers to be reliable and relevant to determine the reasonableness of the disputed fee.

Although the reimbursement rate is not certified by the Department, we believe it is reasonable because:

(explain)

Note: The Department of Workforce Development only certifies a formula amount for a specific code when there are at least 25 observations within the geographic region used to derive the formula amount. Where the certified database contains amounts based on fewer than 25 observations in a designated region, the database may be helpful in determining a reasonable amount of reimbursement, but is not controlling and insurance carriers and self-insured employers may not represent to providers that it is a certified formula amount. If a dispute is submitted to the Department based on fewer than 25 observations, the Department may combine averages from all the certified databases to accumulate 25 or more observations in a region and use that as a reasonable amount to resolve the dispute.