Section 146.903. Disclosures required of health care providers and hospitals.

 

(1)   Definitions. In this section:

(a) “Ambulatory surgical center" has the meaning given in 42 CFR 416.2 .

(b) “Clinic" means a place, other than a residence or a hospital, that is used primarily for the provision of nursing, medical, podiatric, dental, chiropractic, or optometric care and treatment.

(br) “Health care information organization" means an organization that gathers data from health care providers or hospitals regarding utilization and quality of health care services and that produces reports on the comparative quality of health care services provided by health care providers or hospitals.

(c) “Health care provider" has the meaning given in s. 146.81 (1) (a) to (L) and includes a clinic and an ambulatory surgical center but does not include a nursing home, as defined in s. 50.01 (3) .

(d) “Hospital" has the meaning given in s. 50.33 (2) .

(e) “Median billed charge" means one of the following:

1. For a health care provider, the amount the health care provider charged, before any discount or contractual rate applicable to certain patients or payers was applied, during the first 2 calendar quarters of the most recently completed calendar year, as calculated by arranging the charges in that reporting period from highest to lowest and selecting the middle charge in the sequence or, for an even number of charges, selecting the 2 middle charges in the sequence and calculating the average of the 2.

2. For a hospital, the amount the hospital charged, before any discount or contractual rate applicable to certain patients or payers was applied, during the 4 calendar quarters for which the hospital most recently reported data under ch. 153 , as calculated by arranging the charges in the reporting period from highest to lowest and selecting the middle charge in the sequence or, for an even number of charges, selecting the 2 middle charges in the sequence and calculating the average of the 2.

(f) “Medicare" means coverage under part A or part B of Title XVIII of the federal Social Security Act, 42 USC 1395 to 1395dd .

(g) “Public information" means information that any person may access from a health care information organization, regardless of whether the organization charges a fee for the information.

(2)   Department duties.

(a) The department shall do all of the following:

1. Categorize health care providers by type.

2. For each type of health care provider, annually identify the 25 presenting conditions for which that type of health care provider most frequently provides health care services.

3. Prescribe the methods by which health care providers shall calculate and present median billed charges and Medicare and private 3rd-party payer payments under sub. (3) (b) .

(b) In performing the duties under par. (a) , the department shall consult with organizations in this state that do all of the following:

1. Develop performance measures for assessing the quality of health care services.

2. Guide the collection, validation, and analysis of data related to measures described under subd. 1.

3. Report results of assessments of the quality of health care services.

4. Share best practices of organizations that provide health care services.

(3)   Health care provider disclosure of charges.

(a) Except as provided in par. (g) , a health care provider or the health care provider's designee shall, upon request by and at no cost to a health care consumer, disclose to the consumer within a reasonable period of time after the request, the median billed charge, assuming no medical complications, for a health care service, diagnostic test, or procedure that is specified by the consumer and that is provided by the health care provider.

(am) A health care provider that submits data to a health care information organization shall, when it makes a disclosure to a consumer under par. (a) , make available to the consumer any public information reported by the health care information organization regarding the quality of health care services provided by the health care provider compared to the quality of health care services provided by other health care providers that is relevant to the health care service, diagnostic test, or procedure specified by the consumer under par. (a) . A health care provider may make the information available to the consumer by providing the consumer a paper copy of the information or by providing the consumer the address of an Internet site where the information is posted. If the health care provider submits data to more than one health care information organization and more than one of the health care information organizations reports to the health care provider public information on comparative quality that is relevant to the health care service, diagnostic test, or procedure, the health care provider is required under this paragraph to make available to the consumer public information reported by only one of the health care information organizations.

(b) Except as provided in par. (g) , a health care provider shall prepare a single document that lists the following charge information, assuming no medical complications, for diagnosing and treating each of the 25 presenting conditions identified for the health care provider's provider type under sub. (2) :

1. The median billed charge.

2. If the health care provider is certified as a provider of Medicare, the Medicare payment to the provider.

3. The average allowable payment from private, 3rd-party payers.

(bm) A health care provider that submits data to a health care information organization shall make available with the document required under par. (b) any public information reported by the health care information organization regarding the quality of health care services provided by the health care provider compared to the quality of health care services provided by other health care providers that is relevant to a presenting condition for which the provider is required to list charge information under par. (b) . A health care provider may make the information available by attaching it to the document or by including the address of an Internet site where the information is posted with the document. If the health care provider submits data to more than one health care information organization and more than one of the health care information organizations reports to the health care provider public information on comparative quality that is relevant to a presenting condition, the health care provider is required under this paragraph to make available public information reported by only one of the health care information organizations for the presenting condition.

(c) Except as provided in par. (g) , a health care provider or the health care provider's designee shall, upon request by and at no cost to a health care consumer, provide the consumer a copy of the document prepared under par. (b) and the information described under par. (bm) .

(d) Except as provided in par. (g) , a health care provider shall annually update the document under par. (b) .

(e) Information provided upon request under par. (a) or included on the document under par. (b) does not constitute a legally binding estimate of the charge for a specific patient or the amount that a 3rd-party payer will pay on behalf of the patient.

(f) Except as provided in par. (g) , a health care provider shall prominently display, in the area of the health care provider's practice or facility that is most commonly frequented by health care consumers, a statement informing the consumers that they have the right to receive charge information as provided in pars. (a) and (b) and, if applicable, the information described under par. (bm) , from the health care provider and, if the requirements, if any, under s. 632.798 (2) (d) are met, a good faith estimate, from their insurers or self-insured health plans, of the insured's total out-of-pocket cost according to the insured's benefit terms for the specified health care service in the geographic region in which the health care service will be provided.

(g) The requirements under pars. (a) to (f) do not apply to any of the following:

1. A health care provider that practices individually or in association with not more than 2 other individual health care providers.

2. A health care provider that is an association of 3 or fewer individual health care providers.

(4)   Hospital disclosure of charges.

(a) Each hospital shall prepare a single document that lists the following charge information, assuming no medical complications, for inpatient care for each of the 75 diagnosis related groups identified under s. 153.21 (3) and the following charge information for each of the 75 outpatient surgical procedures identified under s. 153.21 (3) :

1. The median billed charge.

2. The average allowable payment under Medicare.

3. The average allowable payment from private, 3rd-party payers.

(am) A hospital that submits data to a health care information organization shall make available with the document required under par. (a) any public information reported by the health care information organization regarding the quality of health care services provided by the hospital compared to the quality of health care services provided by other hospitals that is relevant to a diagnosis related group or outpatient surgical procedure for which the hospital is required to list charge information under par. (a) . A hospital may make the information available by attaching it to the document or by including the address of an Internet site where the information is posted with the document. If a hospital submits data to more than one health care information organization and more than one of the health care information organizations reports to the hospital public information on comparative quality that is relevant to a diagnosis related group or outpatient surgical procedure, the hospital is required under this paragraph to make available public information reported by only one of the health care information organizations for the diagnosis related group or outpatient surgical procedure.

(b) A hospital shall, upon request by and at no cost to a health care consumer, provide the consumer a copy of the document prepared under par. (a) and the information described under par. (am) .

(c) A hospital shall update the document under par. (a) every calendar quarter.

(d) Information included on the document under par. (a) does not constitute a legally binding estimate of the charge for a specific patient or the amount that a 3rd-party payer will pay on behalf of the patient.

(e) Each hospital shall prominently display, in the area of the hospital that is most commonly frequented by health care consumers, a statement informing the consumers that they have the right to receive a copy of the document under par. (a) and, if applicable, the information described under par. (am) , from the hospital and, if the requirements, if any, under s. 632.798 (2) (d) are met, a good faith estimate, from their insurers or self-insured health plans, of the insured's total out-of-pocket cost according to the insured's benefit terms for the specified health care service in the geographic region in which the health care service will be provided.

(5)   Penalty.

(a) Whoever violates sub. (3) or (4) may be required to forfeit not more than $250 for each violation.

(b) The department may directly assess forfeitures provided for under par. (a) . If the department determines that a forfeiture should be assessed for a particular violation, the department shall send a notice of assessment to the alleged violator. The notice shall specify the amount of the forfeiture assessed, the violation, and the statute or rule alleged to have been violated, and shall inform the alleged violator of the right to a hearing under par. (c) .

(c) An alleged violator may contest an assessment of a forfeiture by sending, within 10 days after receipt of notice under par. (b) , a written request for a hearing under s. 227.44 to the division of hearings and appeals created under s. 15.103 (1) . The administrator of the division may designate a hearing examiner to preside over the case and recommend a decision to the administrator under s. 227.46 . The decision of the administrator of the division shall be the final administrative decision. The division shall commence the hearing within 30 days after receipt of the request for a hearing and shall issue a final decision within 15 days after the close of the hearing. Proceedings before the division are governed by ch. 227 . In any petition for judicial review of a decision by the division, the party, other than the petitioner, who was in the proceeding before the division shall be the named respondent.

(d) All forfeitures shall be paid to the department within 10 days after receipt of notice of assessment or, if the forfeiture is contested under par. (c) , within 10 days after receipt of the final decision after exhaustion of administrative review, unless the final decision is appealed and the order is stayed by court order. The department shall remit all forfeitures paid to the secretary of administration for deposit in the school fund.

(e) The attorney general may bring an action in the name of the state to collect any forfeiture imposed under this subsection if the forfeiture has not been paid following the exhaustion of all administrative and judicial reviews. The only issue to be contested in any such action is whether the forfeiture has been paid.

2009 a. 146 .