Section 120.11. Common data verification, review and comment procedures.

 

(1)   Applicability. The data verification, review and comment procedures in this section apply to data submitted by hospitals and ambulatory surgery centers as described in ss. DHS 120.12 (5) (c) and (d) , (5m) (c) and (d) , (6) (d) and (e) and 120.13 (3) and (4) .

(2)   Definition. In this section, "facility" means hospitals and freestanding ambulatory surgery centers.

(3)   Facility data verification, review and comment procedures.

(a) Each facility shall review its collected data for accuracy and completeness before submitting the data to the department.

(b) The department shall check the accuracy and completeness of all submitted data and record all questionable data based on standard edits or the electronic editing features of the department's data submission system.

(c) If the department determines data submitted by the facility to be questionable, and the department has determined that the data cannot be verified or corrected by telephone or electronic means, the department may return the questionable data to the facility or the facility's qualified vendor with information for revision and resubmission.

(d)

1. Within 20 calendar days from the required date for data submission as specified in ss. DHS 120.12 (5) (b) 2. , (5m) (b) 2. , (6) (c) 2. and 120.13 (2) (a) , the facility shall do all of the following:

a. Correct all data errors resulting from the department checks performed under par. (b) .

b. Review the resultant data profile for accuracy and completeness.

c. Supply the department with the affirmation statement that was included with the data profile. The affirmation statement shall be signed by the chief executive officer or designee indicating that the facility's data are accurate and complete. Facilities submitting affirmation statements to the department electronically shall use the digital signature approved by the department and returned by the facility during the timeframes for data submission specified by the department. A signature on the electronic data affirmation statement represents the signatory's acknowledgement that the data is accurate to the best of his or her knowledge and that the data submitter may no longer submit revised data.

2. Failure to comply with subd. 1. shall result in the facility being non-compliant with this subsection and the facility may be subject to forfeitures under this chapter.

(e) After the department has made any revisions under par. (d) in the data for a particular facility, the department shall send the facility all of the following:

1. A final data profile under this subsection.

2. An affirmation statement.

(g) If the department discovers data errors after the department's release of the data or if a facility representative notifies the department of data errors after the department's release of the data, the department shall note the data errors as caveats to the completed datasets.

(4)   Physician verification, review and comment on facility-submitted data.

(a) During the facility-submitted data verification, review and comment procedures described in sub. (3) , the department shall give a physician the opportunity to concurrently review the facility-submitted data associated with the physician's license number.

(b) The department shall notify each physician with a Wisconsin license number appearing in the facility-submitted data of the physician's opportunity to review that data.

(c) The department shall notify each identified physician using the physician's last known address on file with the department of safety and professional services or information provided by the facility that may be more current.

(d) The notice shall include all of the following:

1. A message marked "urgent: dated material."

2. An indication that the physician has 10 working days from the date the notice was sent to notify the department that the physician intends to review the requested data before the data is released.

3. A statement informing the physician that the department will not provide further notice of the physician's right to review if the physician chooses not to review the data at that time.

4. Instructions on how the physician may obtain the data.

(e)

1. If a physician files a timely request to review data before release, the department shall make the data available to the physician as it is submitted to the department. The department's report shall contain a "permission to change" authorization form that may be duplicated in the event of multiple problems.

2. If the physician wants to dispute the data, the physician shall attest to the problem associated with the data on the authorization form, and an authorized representative of the facility shall indicate on the form if the facility agrees to the change.

3. The physician shall return the form to the department within 20 working days after the date on which the data were made available to the physician.

4. When the department receives the signed "permission to change" form, the department shall change the data within the facility dataset before its release.

5. If the facility does not agree to the physician's change, the physician may submit his or her written comments on the data to the department within the same 20 working days after the date of the department transmittal. The facility shall also submit its reason for concluding that the submitted data are correct within the same 20 working days. The department may not change the data submitted by the facility, but shall include both sets of comments with the data released to data requesters.

6. A physician desiring to comment on data he or she submits shall submit his or her comments in a standard electronic word processing format. Comments shall be limited to a maximum of 1000 words. All comments shall be submitted no later than the 20 th working day following the department's transmittal.

(f) If the department receives comments from a physician after the release of data, the department shall retain the comments and provide them as part of the documentation released to future data requesters. The department shall note as caveats to the completed data the subsequent discovery of data errors by either the department or the data submitter after the release of data.

History: Cr. Register, December, 2000, No. 540 , eff. 1-1-01; CR 01-051 : am. (1) and (3) (d) 1., Register September 2001 No. 549 eff. 10-1-01; CR 03-033 : am. (3) (c), (d) 1. (intro.), (4) (e) 1. and 2., r. (3) (f) Register December 2003 No. 576 , eff. 1-1-04; correction in (4) (c) made under s. 13.92 (4) (b) 6. , Stats., Register February 2012 No. 674 .