Wisconsin Administrative Code › Department of Workforce Development › DWD 80-81 - Worker's Compensation › Chapter DWD 80 - Worker's Compensation › Section DWD 80.72 - Health service fee dispute resolution process

Current through June 24, 2024
(1) PURPOSE. The
				purpose of this section is to establish the procedures and requirements for
				resolving a dispute under s.
				102.16(2),
				Stats., between a health service provider and an insurer or self-insured
				employer over the reasonableness of a fee charged by the health service
				provider relating to the examination or treatment of an injured worker, and to
				specify the standards that health service fee data bases must meet for
				certification by the department.
(2) DEFINITIONS. In this section:
(a) "ADA" means American dental
				association.
(b) "Applicant" means
				the person requesting certification of a data base.
(c) "Certified" means approved by the
				department for use in determining the reasonableness of fees.
(d) "CPT code" means the American medical
				association's 1992 physicians' current procedural terminology.
Note: This volume is on file in the offices of the secretary
				  of state and the legislative reference bureau, and in the worker's compensation
				  division of the department, GEF I, room 161, 201 E. Washington Ave., Madison,
				  Wisconsin. Copies can be obtained from local textbook stores or from the
				  American medical association, order department: OP054192, P.O. Box 10950,
				  Chicago, IL 60601.
(e)
				"Data base" means a list of fees for procedures compiled and sorted by CPT
				code, ICD-9-CM code, ADA code, DRG code, or other similar coding which is
				systematically collected, assembled, and updated, and which does not include
				procedures charged under medicare.
(f) "DRG" means a diagnostic related group
				established by the federal health care financing administration.
(g) "Dispute" means a disagreement between a
				health service provider and an insurer or self-insured employer over the
				reasonableness of a fee charged by a health service provider where the insurer
				or self-insured employer refuses to pay part or all of the fee.
(h) "Fee" or "health service fee" means the
				amount charged for a procedure by a health service provider.
(i) "Formula amount" means the mean fee for a
				procedure plus 1.4 standard deviations from that mean as shown by data from a
				certified data base.
(j) "ICD-9-CM"
				means the commission on professional and hospital activities' international
				classification of diseases, 9th revision, clinical modification.
Note: This volume is on file in the offices of the secretary
				  of state and the legislative reference bureau, and in the worker's compensation
				  division of the department, GEF I, room 161, 201 E. Washington Ave., Madison,
				  Wisconsin. Copies can be obtained from local textbook stores, or from
				  superintendent of documents, U.S. government printing office, Washington, D.C.,
				  20402, (stock number 917014000001.
(k) "Procedure" or "health service procedure"
				means any treatment of an injured worker under s.
				102.42,
				Stats.
(L) "Provider" or "health
				service provider" includes a physician, podiatrist, psychologist, optometrist,
				chiropractor, dentist, physician's assistant, advanced practice nurse
				prescriber, therapist, medical technician, or hospital.
(m) "Self-insurer" means an employer who has
				been granted an exemption from the duty to insure under s.
				102.28(2),
				Stats.