102.423
102.423(1) (1) Definitions. In this section:
102.423(1)(a) (a) “Eligible hospital” has the meaning given under s. 50.38 (1) .
102.423(1)(b) (b) “Items or services” means hospital facility services that are “items and services,” as defined under 45 CFR 180.20 .
102.423(2) (2) Applicability.
102.423(2)(a) (a) Subject to par.
(b), this section shall apply to a fee for an item or service only if all of the following apply:
102.423(2)(a)1. 1. The fee is for an item or service that was provided by an eligible hospital.
102.423(2)(a)2. 2. The fee is for an item or service for which the eligible hospital may receive hospital inpatient or hospital outpatient reimbursement from the Medical Assistance program under subch. IV of ch. 49 .
102.423(2)(a)3. 3. The fee was paid within the applicab
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102.423
102.423(1) (1) Definitions. In this section:
102.423(1)(a) (a) “Eligible hospital” has the meaning given under s. 50.38 (1) .
102.423(1)(b) (b) “Items or services” means hospital facility services that are “items and services,” as defined under 45 CFR 180.20 .
102.423(2) (2) Applicability.
102.423(2)(a) (a) Subject to par. (b) , this section shall apply to a fee for an item or service only if all of the following apply:
102.423(2)(a)1. 1. The fee is for an item or service that was provided by an eligible hospital.
102.423(2)(a)2. 2. The fee is for an item or service for which the eligible hospital may receive hospital inpatient or hospital outpatient reimbursement from the Medical Assistance program under subch. IV of ch. 49 .
102.423(2)(a)3. 3. The fee was paid within the applicable period under par. (c) .
102.423(2)(b) (b)
102.423(2)(b)1. 1.
102.423(2)(b)2. 2.
102.423(2)(c) (c)
102.423(2)(c)1. 1. In order for this section to apply to a fee, an insurer or self-insured employer must remit payment for the fee to the eligible hospital within the period specified in subd. 2. , which shall begin to run on the day after whichever of the following dates is latest:
102.423(2)(c)2. 2.
102.423(2)(c)3. 3. An insurer or self-insured employer may request that an eligible hospital send additional medical records to the insurer or self-insured employer that the insurer or self-insured employer reasonably believes are necessary to substantiate the claim. The eligible hospital shall provide the requested records to the extent practicable or within 10 days after the request is received, but a request under this subdivision by an insurer or self-insured employer shall not operate to extend the period specified under subd. 2. a. or b.
102.423(2)(c)4. 4.
102.423(3) (3) Establishment of schedule.
102.423(3)(a) (a) By July 1, 2027, the department shall establish a schedule of the maximum fees that the eligible hospital may charge an insurer or self-insured employer for an item or service provided to an injured employee who claims benefits under this chapter. When the schedule under this subsection is established, the department shall send a notice to the legislative reference bureau for publication in the Wisconsin Administrative Register of the date that the schedule will be effective, which shall be no earlier than the date the notice is published. In determining the maximum fees, the department shall divide the state into 5 regions based on geographical and economic similarity, including similarity in the cost of items and services, and, for each region, shall do all of the following:
102.423(3)(a)1. 1.
102.423(3)(a)2. 2. Set the maximum fee for each item or service included in the schedule at 120 percent of the amount determined under subd. 1. for that region.
102.423(3)(am) (am) The department shall contract with a 3rd party to perform the duties specified under pars. (a) 1. and 2.
102.423(3)(b) (b) Every year, the department shall redetermine the schedule of maximum fees using the procedures specified in par. (a) , subject to par. (am) .
102.423(3)(d) (d) The department shall publish the current fee schedule established under this subsection on the department’s website. Notwithstanding s. 227.10 (1) , the fee schedule need not be promulgated as a rule.
102.423(4) (4) Liability of insurer or self-insured employer.
102.423(4)(a) (a) The liability of an insurer or self-insured employer for an item or service included in a fee schedule established under sub. (3) is limited to the maximum fee allowed under the schedule for the item or service as of the date on which the item or service was provided, any fee agreed to by contract between the insurer or self-insured employer and eligible hospital for the item or service as of that date, or the eligible hospital’s actual fee for the item or service as of that date, whichever is least.
102.423(4)(b) (b) An eligible hospital that provides items or services to an injured employee under this chapter may not collect, or bring an action to collect, from the injured employee any charge that is in excess of the liability of the insurer or self-insured employer under this subsection.
102.423(4)(c) (c) A schedule of maximum fees established under sub. (3) first applies to an item or service provided to an injured employee on the effective date specified in the notice published under sub. (3) (a) .
102.423(4)(d) (d) Payment of a claim pursuant to this section is not an admission of causality or responsibility with respect to any future payments or obligations.
102.423(5) (5) Rules. The department shall, subject to sub. (3) (d) , promulgate rules to implement this section.
[Note: Effective date note NOTE: This section is created by 2025 Wis. Act 15 eff. on the day after the notice from the department of health services under 2025 Wis. Act 15 s. 9119 (4) (b) 1 . is published by the legislative reference bureau in the Wisconsin Administrative Register, except that, if the notice is not published before August 1, 2027, the treatment of this section is void.]