Section 17.28. Health care provider fees.

 

(1)   Purpose. This section implements s. 655.27 (3) , Stats.

(2)   Scope. This section applies to fees charged to providers for participation in the fund, but does not apply to fees charged for operation of the mediation system under s. 655.61 , Stats.

(3)   Definitions. In this section:

(a) "Annual fee" means the amount established under sub. (6) for each class or type of provider.

(b) "Begin operation" means for a provider other than a natural person to start providing health care services in this state.

(bm) "Begin practice" means to start practicing in this state as a medical or osteopathic physician or nurse anesthetist or to become ineligible for an exemption from ch. 655 , Stats.

(c) "Class" means a group of physicians whose specialties or types of practice are similar in their degree of exposure to loss. The specialties and types of practice and the applicable Insurance Services Office, Inc., codes included in each fund class are the following:

1. Class 1: - See PDF for table

2. Class 2: - See PDF for table

3. Class 3: - See PDF for table

4. Class 4: - See PDF for table

(d) "Fiscal year" means each period beginning each July 1 and ending each June 30.

(e) "Permanently cease operation" means for a provider other than a natural person to stop providing health care services with the intent not to resume providing such services in this state.

(f) "Permanently cease practice" means to stop practicing as a medical or osteopathic physician or nurse anesthetist with the intent not to resume that type of practice in this state.

(g) "Primary coverage" means health care liability insurance meeting the requirements of subch. III of ch. 655 , Stats.

(h) "Provider" means a health care provider, as defined in s. 655.001 (8) , Stats.

(hm) "Resident" means a licensed physician engaged in an approved postgraduate medical education or fellowship program in any specialty specified in par. (c) 1. to 4.

(i) "Temporarily cease practice" means to stop practicing in this state for any period of time because of the suspension or revocation of a provider's license, or to stop practicing for at least 90 consecutive days for any other reason.

(3e)   Primary coverage required. Each provider shall ensure that primary coverage for the provider and the provider's employees other than employees excluded from fund coverage under par. (b) , is in effect on the date the provider begins practice or operation and for all periods during which the provider practices or operates in this state. A provider does not have fund coverage for any of the following:

(a) Any period during which primary coverage is not in effect.

(b) Any employee who is a health care practitioner under the circumstances described in s. 655.005 (2) , Stats.

(3h)   Supervision and direction . For the purposes of clarifying s. 655.005 (2) (a) , Stats., health care services that are "under the direction and supervision of a physician or nurse anesthetist" include, but are not limited to the health care services being provided pursuant to and within the scope of the health care practitioner's professional license and:

(a) The health care practitioner is subject to a quality assurance program, peer review process, or other similar program or process that is implemented for and designed to ensure the provision of competent and quality patient care and that program or process also includes participation by a physician or a nurse anesthetist; or

(b) The health care services are provided by the health care practitioner within the scope of standing orders, protocols, procedures or clinical practice guidelines established or approved by a physician or nurse anesthetist.

(3m)   Exemptions; eligibility. A medical or osteopathic physician licensed under ch. 448 , Stats. , or a nurse anesthetist licensed under ch. 441 , Stats. , may claim an exemption from ch. 655 , Stats. , if at least one of the following conditions applies:

(a) The provider will not practice more than 240 hours in the fiscal year.

(c) During the fiscal year, the provider will derive more than 50% of the income from his or her practice from outside this state or will attend to more than 50% of his or her patients outside this state.

(3s)   Late entry to fund.

(a) A provider that begins or resumes practice or operation during a fiscal year, has claimed an exemption or has failed to comply with sub. (3e) may obtain fund coverage during a fiscal year by giving the fund advance written notice of the date on which fund coverage should begin.

(b) The board may authorize retroactive fund coverage for a provider who submits a timely request for retroactive coverage showing that the failure to procure coverage occurred through no fault of the provider and despite the fact that the provider acted reasonably and in good faith. The provider shall furnish the board with an affidavit describing the necessity for the retroactive coverage and stating that the provider has no notice of any pending claim alleging malpractice or knowledge of a threatened claim or of any occurrence that might give rise to such a claim. The authorization shall be in writing, specifying the effective date of fund coverage.

(4)   Annual fees; billing procedures.

(a) Definition. In this subsection, "semimonthly period" means the 1st through the 14th day of a month or the 15th day through the end of a month.

(b) Entry during fiscal year; prorated annual fee. If a provider begins practice or operation or enters the fund under sub. (3s) (b) after the beginning of a fiscal year, the fund shall charge the provider one twenty-fourth of the annual fee for each semimonthly period or part of a semimonthly period from the date fund coverage begins to the next June 30.

(c) Ceasing practice or operation; refunds. A provider or person acting on the provider's behalf shall notify the fund in the form specified by the fund if any of the following occurs:

1. The provider is exempt under sub. (3m) (a) or (c) .

2. The provider is no longer eligible to participate in the fund under s. 655.003 (1) or (3) , Stats.

3. This state is no longer a principal place of practice for the provider.

4. The provider has temporarily or permanently ceased practice or has ceased operation.

5. The provider's classification under sub. (6) has changed.

(cm) Eligibility for exemption; refund. If a provider claims an exemption after paying all or part of the annual fee, the fund shall issue a refund equal to one twenty-fourth of the provider's annual fee for each full semi-monthly period from the date the provider becomes eligible for the exemption to the due date of the next payment. The refund for any past exemption period will be limited to the current fiscal year and the immediate prior fiscal year.

(cs) Ineligibility for fund coverage; refund.

1. If a provider who has paid all or part of the annual fee is or becomes ineligible to participate in the fund under s. 655.003 (1) or (3) , Stats., or because he or she does not practice in this state, the fund shall issue a full refund of any amount the provider paid for fund coverage for which he or she was not eligible.

2. If a provider that has paid all or part of the annual fee is ineligible for fund coverage because the provider is not in compliance with sub. (3e) , the fund shall issue a full refund of the amount paid for the period of noncompliance, beginning with the date the noncompliance began.

(d) Change of classification; increased annual fee.

1. If a provider's change of classification under sub. (6) during a fiscal year results in an increased annual fee, the fund shall adjust the provider's annual fee to equal the sum of the following:

a. One twenty-fourth of the annual fee for the provider's former classification for each full semimonthly period from the due date of the provider's first payment during the current fiscal year to the date of the change.

b. One twenty-fourth of the annual fee for the provider's new classification for each full or partial semimonthly period from the date of the change to the next June 30.

2. The fund shall bill the provider for the total amount of the increase under subd. 1. if the provider has already paid the total annual fee, or shall prorate the increase over the remaining installment payments.

(e) Change of classification; decreased annual fee.

1. If a provider's change of classification under sub. (6) during a fiscal year results in a decreased annual fee, the fund shall adjust the provider's annual fee to equal the sum of the following:

a. One twenty-fourth of the annual fee for the provider's former classification for each full or partial semimonthly period from the due date of the provider's first payment during the current fiscal year to the date of the change.

b. One twenty-fourth of the annual fee for the provider's new classification for each full semimonthly period from the date of the change to the next June 30.

2. The fund shall credit the amount of the decrease under subd. 1. over any remaining installment payments. If the provider has already paid the total annual fee, the fund shall issue a refund if the amount of the refund is more than $10. The fund shall credit any amount of $10 or less to the provider's account. If the provider no longer participates in the fund, a credit of $10 or less shall lapse to the fund.

(f) Refund of other charges. If a provider is entitled to a refund or credit under this subsection, the fund shall also issue a refund or credit of the unearned portion of any amounts paid as administrative service charges, interest or surcharges, using the same method used to calculate a refund or credit of an annual fee. A mediation fund fee is refundable only if the provider did not participate in the patients compensation fund for any part of the fiscal year.

(g) Refund for administrative error. In addition to any refund authorized under par. (c) , (cm) , (cs) , (e) or (f) , the fund may issue a refund to correct an administrative error in the current or any previous fiscal year.

(h) Billing; entire fiscal year. Except as provided in sub. (6e) (b) , for each fiscal year, the fund shall issue to each provider participating in the fund an initial bill which shall include all of the following:

1. The total annual fee due for the fiscal year.

2. Any applicable surcharge imposed under s. Ins 17.285 .

3. The balance and accrued interest, if any, due from a prior fiscal year.

4. Notice of the provider's right to pay the amount due in full or in instalments.

5. The minimum amount due if the provider elects installment payments.

6. The payment due date.

(i) Billing; partial fiscal year. The fund shall issue each provider entering the fund after the beginning of a fiscal year an initial bill which shall include all of the following;

1. The total amount due calculated under par. (b) .

2. Notice of the provider's right to pay the amount due in full or in instalments.

3. The minimum amount due if the provider elects installment payments.

4. The payment due date.

(j) Balance billing. If a provider pays at least the minimum amount due but less than the total amount due by the due date, the fund shall calculate the remainder due by subtracting the amount paid from the amount due and shall bill the provider for the remainder on a quarterly installment basis. Each subsequent bill shall include all of the following:

1. The total of the remainder due.

2. Interest on the remainder due. The daily rate of interest shall be the average annualized rate earned by the fund on its short-term funds for the first 3 quarters of the preceding fiscal year, as determined by the state investment board, divided by 360.

3. A $3 administrative service charge.

4. The minimum amount due.

5. The payment due date.

(k) Prompt payment required. A provider shall pay at least the minimum amount due on or before each due date. If the fund receives payment later than the due date specified in the late payment notice sent to the provider by certified mail, the fund, notwithstanding par. (n) 5. , may not apply the payment retroactively to the annual fee unless the board has authorized retroactive coverage under sub. (3s) (b) .

(n) Application of payments. Except as provided in par. (k) , all payments to the fund shall be applied in chronological order first to previous fiscal years for which a balance is due and then to the current fiscal year. The amounts for each fiscal year shall be credited in the following order:

1. Mediation fund fee imposed under s. Ins 17.01 .

2. Administrative service charge under par. (j) 3.

3. Interest under par. (j) 2.

4. Surcharge imposed under s. Ins 17.285 .

5. Annual fee under sub. (6) .

(o) Waiver of balance. The fund may waive any balance of $50 or less, if it is in the economic interest of the fund to do so.

(5)   Filing of certificates of insurance.

(a) Electronic filing. Except as provided in par. (b) , each insurer and self-insured provider required under s. 655.23 (3) (b) or (c) , Stats., to file a certificate of insurance shall file the certificate electronically in the format specified by the commissioner by the 15th day of the month following the month of original issuance or renewal or a change of class under sub. (6) .

(b) Exemption. An insurer or self-insured provider may file a written request for an exemption from the requirement of par. (a) . The commissioner may grant the exemption if he or she finds that compliance would constitute a financial or administrative hardship. An insurer or self-insured provider granted an exemption under this paragraph shall file a paper certificate in the format specified by the commissioner within 45 days after original issuance or renewal or a change of class under sub. (6) .

(c) Late filing fee. A late fee in the amount of $100.00 per certificate shall be paid to the fund by each insurer and self-insured provider who fails to file a certificate of insurance in accordance with the requirements of this subsection. An additional $100.00 late fee shall be paid per certificate for each additional week, or portion thereof, the certificate is not in compliance with this subsection.

(6)   Fee schedule. The following fee schedule is in effect from July 1, 2013 to June 30, 2014:

(a) Except as provided in pars. (b) to (f) and sub. (6e) , for a physician for whom this state is a principal place of practice:

Class 1   $1,457   Class 3   $5,828

Class 2   $2,623   Class 4   $9,616

(b) For a resident acting within the scope of a residency or fellowship program:

Class 1   $ 729   Class 3   $2,916

Class 2   $1,312   Class 4   $4,811

(c) For a resident practicing part-time outside the scope of a residency or fellowship program:

All classes   $874

(d) For a Medical College of Wisconsin, Inc., full-time faculty member:

Class 1   $583   Class 3   $2,332

Class 2   $1,049   Class 4   $3,848

(e) For physicians who practice part-time:

1. For a physician who practices fewer than 500 hours during the fiscal year, limited to office practice and nursing home and house calls, and who does not practice obstetrics or surgery or assist in surgical procedures:   $ 364

2. For a physician who practices 1,040 hours or less during the fiscal year, including those who practice fewer than 500 hours during the fiscal year whose practice is not limited to office practice, nursing homes or house calls or who do practice obstetrics, surgery or assist in surgical procedures:

Class 1   $ 874   Class 3   $3,496

Class 2   $1,573   Class 4   $5,768

(f) For a physician for whom this state is not a principal place of practice:

Class 1   $ 729   Class 3   $2,916

Class 2   $1,312   Class 4   $4,811

(g) For a nurse anesthetist for whom this state is a principal place of practice:   $ 358

(h) For a nurse anesthetist for whom this state is not a principal place of practice:   $ 179

(i) For a hospital, all of the following fees:

1. Per occupied bed   $ 87

2. Per 100 outpatient visits during the last calendar year for which totals are available:   $ 4.35

(j) For a nursing home, as described under s. 655.002 (1) (j) , Stats., that is wholly owned and operated by a hospital and that has health care liability insurance separate from that of the hospital by which it is owned and operated:

Per occupied bed     $ 17

(k) For a partnership comprised of physicians or nurse anesthetists, organized for the primary purpose of providing the medical services of physicians or nurse anesthetists, all of the following fees:

1.

a. If the total number of partners and employed physicians and nurse anesthetists is from 2 to 10   $ 51

b. If the total number of partners and employed physicians and nurse anesthetists is from 11 to 100   $ 503

c. If the total number of partners and employed physicians and nurse anesthetists exceeds 100   $1,252

2. The following fee for each full-time equivalent allied health care professional employed by the partnership as of the most recent completed survey submitted:

Employed Health Care Professionals   Fund Fee

Nurse Practitioners   $ 364

Advanced Nurse Practitioners   510

Nurse Midwives     3,205

Advanced Nurse Midwives   3,351

Advanced Practice Nurse Prescribers   510

Chiropractors     583

Dentists     291

Oral Surgeons     2,186

Podiatrists-Surgical   6,192

Optometrists       291

Physician Assistants   291

(L) For a corporation, including a service corporation, with more than one shareholder organized under ch. 180 , Stats. , for the primary purpose of providing the medical services of physicians or nurse anesthetists, all of the following fees:

1.

a. If the total number of shareholders and employed physicians and nurse anesthetists is from 2 to 10   $ 51

b. If the total number of shareholders and employed physicians and nurse anesthetists is from 11 to 100   $ 503

c. If the total number of shareholders and employed physicians or nurse anesthetists exceeds 100   $1,252

2. The following fee for each full-time equivalent allied health care professional employed by the corporation as of the most recent completed survey submitted:

Employed Health Care Professionals   Fund Fee

Nurse Practitioners     $ 364

Advanced Nurse Practitioners   510

Nurse Midwives     3,205

Advanced Nurse Midwives     3,351

Advanced Practice Nurse Prescribers   510

Chiropractors     583

Dentists     291

Oral Surgeons     2,186

Podiatrists-Surgical     6,192

Optometrists     291

Physician Assistants     291

(m) For a corporation organized under ch. 181 , Stats. , for the primary purpose of providing the medical services of physicians or nurse anesthetists, all of the following fees:

1.

a. If the total number of employed physicians and nurse anesthetists is from 1 to 10   $ 51

b. If the total number of employed physicians and nurse anesthetists is from 11 to 100   $ 503

c. If the total number of employed physicians or nurse anesthetists exceeds 100   $1,252

2. The following fee for each full-time equivalent allied health care professional employed by the corporation as of the most recent completed survey submitted:

Employed Health Care Professionals   Fund Fee

Nurse Practitioners   $ 364

Advanced Nurse Practitioners   510

Nurse Midwives     3,205

Advanced Nurse Midwives   3,351

Advanced Practice Nurse Prescribers   510

Chiropractors     583

Dentists     291

Oral Surgeons     2,186

Podiatrists-Surgical   6,192

Optometrists     291

Physician Assistants   291

(n) For an operational cooperative sickness care plan as described under s. 655.002 (1) (f) , Stats., all of the following fees:

1. Per 100 outpatient visits during the last calendar year for which totals are available   $0.11

2. 2.5% of the total annual fees assessed against all of the employed physicians.

3. The following fee for each full-time equivalent allied health care professional employed by the operational cooperative sickness plan as of the most recent completed survey submitted:

Employed Health Care Professionals   Fund Fee

Nurse Practitioners   $ 364

Advanced Nurse Practitioners   510

Nurse Midwives   3,205

Advanced Nurse Midwives   3,351

Advanced Practice Nurse Prescribers   510

Chiropractors     583

Dentists     291

Oral Surgeons     2,186

Podiatrists-Surgical   6,192

Optometrists     291

Physician Assistants   291

(o) For a freestanding ambulatory surgery center, as defined in s. DHS 120.03 (13) , per 100 outpatient visits during the last calendar year for which totals are available:   $ 22.73

(p) For an entity affiliated with a hospital, the greater of $100 or whichever of the following applies:

1. 7.0% of the amount the entity pays as premium for its primary health care liability insurance, if it has occurrence coverage.

2. 10.0% of the amount the entity pays as premium for its primary health care liability insurance, if it has claims-made coverage.

(q) For an organization or enterprise not specified as a partnership or corporation that is organized and operated in this state for the primary purpose of providing the medical services of physicians or nurse anesthetists, all of the following fees:

1.

a. If the total number of employed physicians and nurse anesthetists is from 1 to 10   $ 51

b. If the total number of employed physicians and nurse anesthetists is from 11 to 100   $ 503

c. If the total number of employed physicians or nurse anesthetists exceeds 100   $ 1,252

2. The following for each full-time equivalent allied health care professional employed by the organization or enterprise not specified as a partnership, corporation, or an operational cooperative health care plan as of the most recent completed survey submitted:

Employed Health Care Professionals   Fund Fee

Nurse Practitioners   $ 364

Advanced Nurse Practitioners   510

Nurse Midwives   3,205

Advanced Nurse Midwives   3,351

Advanced Practice Nurse Prescribers   510

Chiropractors     583

Dentists     291

Oral Surgeons   2,186

Podiatrists-Surgical   6,192

Optometrists     291

Physician Assistants   291

(6d)   Primary purpose presumption. For purposes of s. 655.002 (1) (e) , Stats., and this section, it is presumed:

(a) A corporation organized and operated in this state of which 50% or more of its shareholders are physicians or nurse anesthetists is organized and operated in this state for the primary purpose of providing the medical services of physicians or nurse anesthetists.

(b) Conclusively that a corporation organized and operated in this state of which less than 50% of its shareholders are physicians or nurse anesthetists is not organized and operated in this state for the primary purpose of providing the medical services of physicians or nurse anesthetists.

(6e)   Medical college residents' fees.

(a) The fund shall calculate the total amount of fees for all medical college of Wisconsin affiliated hospitals, inc., and UW hospital and clinics, residents on a full-time-equivalent basis, taking into consideration the proportion of time spent by the residents in practice which is not covered by the fund, including practice in federal, state, county and municipal facilities, as determined and documented by the medical college of Wisconsin affiliated hospitals, inc., and UW hospital and clinics, respectively.

(b) Notwithstanding sub. (4) (h) , the fund's initial bill for each fiscal year shall be the amount the medical college of Wisconsin affiliated hospitals, inc., estimates will be due for the next fiscal year for all its residents. At the end of the fiscal year, the fund shall adjust the fee to reflect the residents' actual exposure during the fiscal year, as determined by the medical college of Wisconsin affiliated hospitals, inc., and shall bill the medical college of Wisconsin affiliated hospitals, inc., for the balance due, if any, plus accrued interest, as calculated under sub. (4) (j) 2. , from the beginning of the fiscal year. The fund shall refund the amount of an overpayment, if any.

(6m)   Reporting.

(a) The fund may require any provider to report, at the times and in the manner prescribed by the fund, any information necessary for the determination of a fee specified under sub. (6) .

(b) For purposes of sub. (6) (k) to (m) , a partnership or corporation shall report the number of partners, shareholders and employed physicians and nurse anesthetists on July 1 of the previous fiscal year.

(6s)   Surcharge.

(a) This subsection implements s. 655.27 (3) (bg) 1. , Stats., requiring the establishment of an automatic increase in a provider's fund fee based on loss and expense experience.

(b) In this subsection:

1. "Aggregate indemnity" has the meaning given under s. Ins 17.285 (2) (a) .

2. "Closed claim" has the meaning given under s. Ins 17.285 (2) (b) .

3. "Provider" has the meaning given under s. Ins 17.285 (2) (d) .

4. "Review period" has the meaning given under s. Ins 17.285 (2) (e) .

(c) The following tables shall be used in making the determinations required under s. Ins 17.285 as to the percentage increase in a provider's fund fee:

1. For a class 1 physician or a nurse anesthetist: - See PDF for table

2. For a class 2 physician: - See PDF for table

3. For a class 3 physician: - See PDF for table

4. For a class 4 physician: - See PDF for table

History: Cr. Register, June, 1980, No. 294 , emerg. r. and recr. (6) and am. (6a), eff. 7-1-00; r. and recr. (6) and am. (6a), Register, August, 2000, No. 536 , eff. 9-1-00; emerg. r. and recr. (6) and am. (6a), eff. 7-1-01; CR 01-035 : r. and recr. (6) and am. (6a), Register September 2001 No. 549 , eff. 10-1-01; emerg. r. and recr. (6), r. (6a), eff. 7-1-02; CR 02-035 : r. and recr. (6), r. (6a), Register September 2002 No. 561 , eff. 10-1-02; CR 03-039 : r. and recr. (6) Register October 2003 No. 574 , eff. 11-1-03; CR 04-032 : r. and recr. (6) Register January 2005 No. 589 , eff. 2-1-05; emerg. r. and recr. (6), eff. 7-1-05; CR 05-028 : r. and recr. (6) Register October 2005 No. 598 , eff. 11-1-05; CR 06-002 : am. (3) (c) 1. and 2. and r. and recr. (6) Register June 2006 No. 606 , eff. 7-1-06; CR 07-002 : am. (6), Register June 2007 No. 618 , eff. 7-1-07; CR 07-002 : am. (6e), Register June 2007 No. 618 , eff. 7-1-07; CR 08-006 : am. (6) (intro.), (k) 2., (L) 2., (m) 2., (n) 3. and (q) 2. Register June 2008 No. 630 , eff. 7-1-08; CR 09-004 : am. (3) (c), r. and recr. (6) Register June 2009 No. 642 , eff. 7-1-09; correction in (6) (o) made under s. 13.92 (4) (b) 7. , Stats., Register June 2009 No. 642 ; CR 09-055 : cr. (3h) Register March 2010 No. 651 , eff. 4-1-10; EmR1020 : emerg. r. and recr. eff. 6-15-10; CR 10-065 : r. and recr. Register November 2010 No. 659 , eff. 12-1-10; correction in (6) (o) made under s. 13.92 (4) (b) 7. , Stats., Register November 2010 No. 659 ; EmR1108 : emerg. am. (3) (c), r. and recr. (6) eff. 6-10-11; CR 11-015 : am. (3) (c), r. and recr. (6) and Register August 2011 No. 668 , eff. 9-1-11; EmR1306 : emerg. am. (3) (c) 1. to 3., r. and recr. (6), eff. 6-3-13; CR 13-044 : am. (3) (c) 1. to 3., r. and recr. (6) Register June 2014 No. 702 , eff. 7-1-14.

Note

A person who disputes the application of this presumption to the person may be entitled to a hearing on the issue in accordance with s. 227.42 , Stats. Microsoft Windows NT 6.1.7601 Service Pack 1 For a complete history of s. Ins 17.28 from June 1980 through August 31, 2000, see the History note following s. Ins 17.28 published in Register August 2000 No. 536 . Microsoft Windows NT 6.1.7601 Service Pack 1