SB275: Bill Text

Under this bill, the Chiropractic Examining Board must establish a Peer Review Panel of qualified chiropractors to evaluate a claim that a chiropractor provided inappropriate care to a patient. Under the bill, a finding by the Peer Review Panel that the chiropractor has provided a certain number of inappropriate services to a patient constitutes misconduct for which his or her license may be suspended or revoked. The provisions regarding the Peer Review Panel do not apply 30 months after the bill's effective date.

The bill creates several new categories of misconduct for which a chiropractor may have his or her license suspended, including improper billing and falsifying an insurance claim. In addition, under the bill, the Chiropractic Examining Board must suspend the license of a chiropractor who commits a third misconduct violation, for no less than six months. For a fourth misconduct violation, the bill requires license suspension for no less than two years. The bill also provides grounds for disciplining a chiropractor who is found to provide chiropractic care that is not necessary for treating a patient. In addition, if the Peer Review Panel makes certain findings, the bill requires the Chiropractic Examining Board to assess a forfeiture against a chiropractor who provides inappropriate, unnecessary, or substandard care in an amount equal to three times the amount billed for the care or $5,000, whichever is less.

Finally, the bill prohibits sexual misconduct by chiropractors. Sexual misconduct is sexual contact, exposure, or gratification, sexually offensive communication, dating a patient while the patient is under the chiropractor's professional care or treatment or within six months after discharge from care or treatment, or other sexual behavior with or in the presence of a patient under the chiropractor's professional care or treatment. Consent is not relevant. A chiropractor who commits sexual misconduct that does not involve physical contact with a patient shall have his or her license suspended for not less than 90 days. A chiropractor who commits a second act of sexual misconduct that does not involve physical contact or a first act of sexual misconduct that does involve physical contact shall have his or her license suspended for one year, and a chiropractor who commits a third act of sexual misconduct that does not involve physical contact or a second act of sexual misconduct that does involve physical contact shall have his or her license revoked.

Delegations by chiropractors

Under current law, a chiropractor licensed by the Chiropractic Examining Board is allowed to delegate services that are adjunctive to the practice of chiropractic to individuals who are not licensed by the Chiropractic Examining Board, but only if the services are performed under the direct, on-premises supervision of the chiropractor.

The bill requires a chiropractor who applies to renew his or her license to identify each employee to whom clinical work is delegated, except that the following do not have to be identified: nurses, physical therapists, and athletic trainers. In addition, if the Chiropractic Examining Board has promulgated rules that require an employee who is required to be identified to complete a training program or course of instruction to perform the delegated work, the chiropractor must also provide in his or her application for renewal the name, date, and sponsoring organization for the training program or course of instruction that the employee completed.

Finally, the bill changes the definitions of "practical nursing" and "professional nursing" to include actions taken under the supervision or direction of a chiropractor, in addition to actions taken under the supervision or direction of other health care professionals that are specified under current law.

Continuing education

Under current law, a chiropractor licensed by the Chiropractic Examining Board must complete any continuing education that the board requires in order to renew his or her license, which must be renewed every two years. This bill creates additional requirements regarding continuing education.

Under the bill, the Chiropractic Examining Board must establish the minimum number of hours of continuing education courses that must be completed during the two-year licensure period. As under current law, a chiropractor does not have to begin complying with continuing education requirements under the bill until the first two-year licensure period beginning after he or she initially receives his or her license.

Also under the bill, only courses that are approved by the Chiropractic Examining Board may be used to satisfy the minimum hours required. The Chiropractic Examining Board may only approve a course if the organization that sponsors the course (sponsoring organization) satisfies certain requirements. The sponsoring organization must be the Wisconsin, American, or International Chiropractic Association, or an accredited chiropractic, medical, or osteopathic college or university. Also, the sponsoring organization must carry out specified duties, including selecting the course instructor, preparing course materials, evaluating the course, maintaining transcripts, performing financial administration, proctoring attendance, providing attendance vouchers, and supplying a list of attendees to the Chiropractic Examining Board. The sponsoring organization is also allowed to delegate these duties to another organization. The Chiropractic Examining Board must withdraw or withhold approval from a sponsoring organization for a 90-day period if the sponsoring organization fails to carry out any of the duties, or if an organization to which a duty is delegated fails to carry out any of the duties.

The bill requires the Chiropractic Examining Board periodically to publish an updated list of approved courses. A chiropractor who applies to renew his or her license must identify the courses used to satisfy the minimum hour requirement on a form provided by the Department of Regulation and Licensing. The bill requires the Department of Regulation and Licensing to audit a percentage, as determined by the department, of the renewal applications received during each 90-day licensure period to determine whether an applicant has attended the courses that he or she identifies on the form.

Finally, the bill allows the Chiropractic Examining Board to take disciplinary action against a licensed chiropractor who violates any state law or rule regulating chiropractors, including the continuing education requirements.

Nutritional guidance

This bill requires certain chiropractors licensed by the Chiropractic Examining Board to complete a postgraduate course of study in nutrition before they may provide counsel, guidance, direction, advice, or recommendations to patients regarding the health benefits of vitamins, herbs, or nutritional supplements. However, the requirement applies only to chiropractors who were granted licenses on or before January 1, 2003. In addition, the requirement does not apply to chiropractors who are also certified as dietitians by the Dietitians Affiliated Credentialing Board. The required course of study must consist of 48 hours and must be approved by the Chiropractic Examining Board.

For further information see the state fiscal estimate, which will be printed as an appendix to this bill.

The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:

SB275, s. 1 Section 1. 446.01 (1d) of the statutes is created to read:

SB275,5,4 446.01 (1d) "Generally accepted standards" means a level of diagnosis, care, skill, and treatment that is recognized by a reasonably prudent chiropractor as being appropriate under similar conditions and circumstances.

SB275, s. 2 Section 2. 446.01 (1k) of the statutes is created to read:

SB275,5,8 446.01 (1k) "Patient" means an individual who receives treatment or services from a chiropractor or who has received treatment or services under the supervision, direction, or delegation of a chiropractor.

SB275, s. 3 Section 3. 446.01 (1L) of the statutes is created to read:

SB275,5,10 446.01 (1L) "Pattern of conduct" means more than one occurrence.

SB275, s. 4 Section 4. 446.01 (1m) of the statutes is created to read:

SB275,5,15 446.01 (1m) "Peer review" means an evaluation based on generally accepted standards, by a peer review panel appointed under s. 446.035 (1), of the appropriateness, quality, and utilization of chiropractic health care provided to a patient or the conduct of a chiropractor alleged to have violated s. 446.04 (11).

SB275, s. 5 Section 5. 446.01 (2) (b) of the statutes is amended to read:

SB275,5,20 446.01 (2) (b) To employ or apply chiropractic adjustments, and the principles or techniques of chiropractic science, that are taught at a chiropractic college or university approved by the Council on Chiropractic Education or its successor, in the diagnosis, treatment or prevention of any of the conditions described in s. 448.01 (10).

SB275, s. 6 Section 6. 446.01 (3) of the statutes is created to read:

SB275,6,2 446.01 (3) "Utilization" means the treatment or services provided to a patient, including the frequency and duration of the treatment or services.

SB275, s. 7 Section 7. 446.02 (1) (b) of the statutes is amended to read:

SB275,6,12 446.02 (1) (b) Meets the requirements of continuing education for license renewal as the examining board may require under s. 446.025. During the time between initial licensure and commencement of a full 2-year licensure period new licensees shall not be required to meet continuing education requirements. Any person who has not engaged in the practice of chiropractic for 2 years or more, while holding a valid license under this chapter, and desiring to engage in such practice, shall be required by the examining board to complete a continuing education course at a school of chiropractic approved by the examining board or pass a practical examination administered by the examining board or both.

SB275, s. 8 Section 8. 446.02 (2) (b) of the statutes is amended to read:

SB275,6,21 446.02 (2) (b) The examining board shall promulgate rules establishing educational requirements for obtaining a license under par. (a). The rules shall require that an application for the license that is received by the department after June 30, 1998, be accompanied by satisfactory evidence that the applicant has a bachelor's degree from a college or university accredited by an accrediting body listed as nationally recognized by the secretary of the federal department of education, and has graduated from a college or university of chiropractic approved by the examining board accredited by the Council on Chiropractic Education or its successor.

SB275, s. 9 Section 9. 446.02 (4) of the statutes is amended to read:

SB275,7,10 446.02 (4) The renewal date and renewal fee for all licenses granted by the examining board are specified under s. 440.08 (2) (a). In an application for renewal, the applicant shall identify each employee, other than a nurse licensed under ch. 441, physical therapist licensed under subch. III of ch. 448, or athletic trainer licensed under subch. VI of ch. 448, to whom clinical work is delegated. If the examining board has promulgated rules requiring such an employee to complete a training program or course of instruction to perform the delegated work, the applicant shall also provide the name, date, and sponsoring organization for the training program or course of instruction that the employee completed. Except as provided in sub. (1) (b), the examining board may not renew a license unless the applicant for renewal identifies on a form provided by the department the continuing education courses approved under s. 446.025 (2) that the applicant has completed to satisfy the minimum number of hours required under s. 446.025 (1).

SB275, s. 10 Section 10. 446.02 (6m) of the statutes is created to read:

SB275,7,17 446.02 (6m) (a) Except as provided in par. (b), a chiropractor who is granted a license under this chapter on or before January 1, 2003, may provide counsel, guidance, direction, advice, or recommendations to a patient regarding the health benefits of vitamins, herbs, or nutritional supplements only if the chiropractor has completed 48 hours in a postgraduate course of study in nutrition that is approved by the examining board.

SB275,7,19 (b) Paragraph (a) does not apply to a chiropractor licensed under this chapter who is certified as a dietitian under subch. V of ch. 448.

SB275, s. 11 Section 11. 446.02 (7s) of the statutes is created to read:

SB275,8,5 446.02 (7s) (a) A chiropractor shall evaluate each patient to determine whether the patient has a condition that is treatable by chiropractic means. An evaluation shall be based on an examination that is appropriate to the patient. In conducting an evaluation, a chiropractor shall utilize chiropractic science, as defined by rule by the examining board, and the principles of education and training of the chiropractic profession. A chiropractor shall discontinue treatment by chiropractic means if, at any time, the chiropractor determines, or reasonably should have determined, that the patient's condition will not respond to further treatment by chiropractic means, except that a chiropractor may provide supportive care to a patient being treated by another health care professional.

SB275,8,11 (b) If a chiropractor determines, or reasonably should have determined, at any time, that a patient has a condition that is not treatable by chiropractic means, or will not respond to further treatment by chiropractic means, the chiropractor shall inform the patient and refer the patient to a physician licensed under subch. II of ch. 448. In making a referral under this paragraph, a chiropractor shall do one of the following:

SB275,8,14 1. Make a written referral to the physician that describes the chiropractor's findings, provide a copy of the written referral to the patient, and maintain a copy of the written referral in the patient record under sub. (7m) (a).

SB275,8,19 2. Make an oral referral to the physician or the physician's staff that describes the chiropractor's findings, notify the patient about the referral, make a written record of the referral, including the name of the physician or staff member and date of the referral, and maintain the written record in the patient record under sub. (7m) (a).

SB275, s. 12 Section 12. 446.02 (9) (a) of the statutes is amended to read:

SB275,9,5 446.02 (9) (a) A student or graduate of a college or university of chiropractic that is accredited by the Council on Chiropractic Education or its successor who practices chiropractic, in a program for the clinical training of students and graduates that is reviewed and approved by the examining board, under the supervision of a chiropractor who is approved by the examining board to supervise the clinical training of the student or graduate and who is licensed under this chapter and is responsible for the student's or graduate's practice in an infirmary, clinic, hospital or private chiropractic office that is connected or associated for training purposes with a college or university of chiropractic approved by the examining board that is accredited by the Council on Chiropractic Education or its successor.

SB275, s. 13 Section 13. 446.025 of the statutes is created to read:

SB275,9,13 446.025 Continuing education. (1) The examining board shall specify the minimum number of hours of continuing education courses that, except as provided in s. 446.02 (1) (b), an applicant for renewal of a license under this chapter is required to complete during a 2-year licensure period. Only courses approved by the examining board under sub. (2) may be used to satisfy the hours required. The examining board shall periodically publish updated lists of the courses that are approved under sub. (2).

SB275,9,15 (2) (a) The examining board may not approve a continuing education course unless the organization that sponsors the course satisfies all of the following:

SB275,9,20 1. The organization is the Wisconsin, American, or International Chiropractic Association or its successor, a college or university of chiropractic accredited by the Council on Chiropractic Education or its successor, or a college or university of medicine or osteopathy accredited by an accrediting body listed as nationally recognized by the secretary of the federal department of education.

SB275,9,21 2. The organization selects the instructor for the course.

SB275,9,25 3. The organization establishes the objectives of the course, prepares course materials, evaluates the subject matter prepared by the instructor, conducts a post-course evaluation, maintains course transcripts, and performs financial administration necessary for the course.

SB275,10,2 4. The organization proctors course attendance through an on-site representative to whom the organization provides written guidelines.

SB275,10,3 5. The organization provides attendance vouchers to course attendees.

SB275,10,5 6. The organization supplies a list of course attendees to the examining board in a manner prescribed by the examining board.

SB275,10,9 (b) Notwithstanding par. (a), the examining board may approve a continuing education course sponsored by an organization that does not satisfy a requirement under par. (a) 2. to 5. if the organization delegates satisfaction of the requirement to another organization and the other organization satisfies the requirement.

SB275,10,17 (3) If an organization that sponsors a course approved under sub. (2) fails to satisfy any requirement under sub. (2) (a) 2. to 5., the examining board shall, for a period of 90 days, withdraw or withhold approval of all continuing education courses sponsored by the organization. If an organization to whom satisfaction of any requirement under sub. (2) (a) 2. to 5. is delegated under sub. (2) (b) fails to satisfy the requirement, the examining board shall, for a period of 90 days, withdraw or withhold approval of all continuing education courses sponsored by the organization that made the delegation.

SB275,10,21 (4) During each 2-year licensure period, the department shall audit a percentage, as determined by the department, of the applications for renewal of a license under this chapter to verify that an applicant has completed the continuing education courses identified by the applicant under s. 446.02 (4).

SB275, s. 14 Section 14. 446.03 (intro.) of the statutes is amended to read:

SB275,11,2 446.03 Reprimand; license revocation, limitation or suspension. (intro.) The Subject to ss. 446.04 (11) (d) and 446.05 (3), the examining board, by order, may reprimand a licensee or registrant and may deny, limit, suspend or revoke any license or certificate of registration if the licensee or registrant:

SB275, s. 15 Section 15. 446.03 (8) of the statutes is created to read:

SB275,11,5 446.03 (8) Has violated this chapter or any rule promulgated under this chapter.

SB275, s. 16 Section 16. 446.035 of the statutes is created to read:

SB275,11,9 446.035 Peer review. (1) Appointment of peer review panel. (a) The examining board shall appoint a peer review panel of no fewer than 6 nor more than 12 members, pursuant to par. (b).

SB275,11,13 (b) The examining board may solicit nominations for the peer review panel pursuant to a process developed by the department. The examining board shall consider the recommendations of the Wisconsin Chiropractic Association regarding nominations.

SB275,11,14 (c) A nominee under par. (b) shall:

SB275,11,15 1. Possess a valid license to practice chiropractic in this state.

SB275,11,20 2. Have no less than 10 years in practice for a minimum of 20 hours per week within the preceding 2 years of his or her nomination for the peer review panel or, if the nominee is not in active practice at the time of his or her nomination due to a disability, have at least 5 years of practice for a minimum of 20 hours per week prior to the onset of his or her disability.

SB275,11,25 3. Be diplomate eligible in a specialty that requires at least 300 hours of postgraduate credit hours that are approved by the American Chiropractic Association or the International Chiropractors Association or that are provided through a single unified program at a college or university of chiropractic accredited by the Council on Chiropractic Education or its successor.

SB275,12,2 4. Not have been subject to disciplinary action under this chapter or by any regulatory or government agency.

SB275,12,4 5. Have completed an annual utilization review course approved by the examining board.

SB275,12,7 (d) The examining board may summarily remove a chiropractor from the peer review panel if the board finds that the reviewer is unqualified or if it finds that the reviewer's methods or practices are unprofessional.

SB275,12,13 (2) Procedure. (a) A patient, a chiropractor, an insurer, or the examining board may request a peer review, if the cost of the care in dispute for a course of treatment exceeds $500, by submitting a written request to the department and any fee required under par. (b). Within 5 business days of submitting the request, the patient, chiropractor, insurer, or examining board shall submit the following documents to the department:

SB275,12,14 1. A written statement of the matter he or she wishes to be reviewed.

SB275,12,16 2. Clinical documentation relating to the course of treatment or the conduct he or she wishes to be reviewed.

SB275,12,18 3. Any other information the patient, chiropractor, insurer, or examining board wishes to include to support his or her request for review.

SB275,12,22 (b) The department shall charge a patient, chiropractor, or insurer that requests a peer review a fee of $275. The department shall adjust the fee each year to reflect adjustments to the U.S. consumer price index for all consumers, U.S. city average, as determined by the U.S. department of labor.

SB275,13,2 (c) Within 15 business days of receipt of the documents and fee specified under par. (a), the department shall notify each patient, chiropractor, or insurer named in the request for review. Within 10 business days of receiving notification that a review has been requested, the patient, chiropractor, or insurer shall submit the following to the department:

SB275,13,3 1. A written statement of response to the matter that is being reviewed.

SB275,13,5 2. Clinical documentation relating to the course of treatment or conduct that is being reviewed.

SB275,13,7 3. Any other information the patient, chiropractor, or insurer wishes to include to support his or her response.

SB275,13,14 (d) The department shall remove identifying information regarding a chiropractor named in the request for review and, within 5 business days of receipt, shall forward all of the documents received under pars. (a) and (c) and payment of $235 to a peer reviewer chosen at random from the peer review panel. The department shall adjust the fee each year to reflect adjustments to the U.S. consumer price index for all consumers, U.S. city average, as determined by the U.S. department of labor.

SB275,13,24 (e) Within 30 business days of receiving the documents specified in par. (d), the peer reviewer shall make a determination of the quality, appropriateness, or utilization of the chiropractic services rendered to the patient. The peer reviewer shall determine that the chiropractor acted unprofessionally if he or she finds that, applying generally accepted standards, 50% or more of the chiropractic services identified in the request for peer review were inappropriate, unnecessary, or of substandard quality. The peer reviewer shall sign, with his or her name and address, and remit his or her findings to the department and the department shall issue a copy of the findings to each patient, chiropractor, or insurer named in the request and to the examining board.

SB275,14,6 (f) Within 30 days after the date of receipt of the peer reviewer's findings, a patient, chiropractor, insurer, or the examining board may request an appeal. The person requesting the appeal shall submit a written request to the department and pay a fee of $750. The department shall adjust the fee each year to reflect adjustments to the U.S. consumer price index for all consumers, U.S. city average, as determined by the U.S. department of labor.

SB275,14,23 (g) Upon receipt of a request for appeal and the fee specified in par. (f), the department shall forward all of the documents received under pars. (a), (c), and (e) and a payment of $235 each to 3 additional peer reviewers chosen at random from the peer review panel. The department shall adjust the fee each year to reflect adjustments to the U.S. consumer price index for all consumers, U.S. city average, as determined by the U.S. department of labor. The reviewers shall conduct a joint review of the submitted materials. Each peer reviewer shall determine that the chiropractor acted unprofessionally if he or she finds that, applying generally accepted standards, 50% or more of the chiropractic services identified in the request for peer review were inappropriate, unnecessary, or of substandard quality. Each peer reviewer shall sign, with his or her name and address, and remit his or her findings to the department. The department shall forward a copy of the joint review to each patient, chiropractor, or insurer named in the request for peer review. The department shall adopt the determination reached by a majority of the peer reviewers appointed under this paragraph of the quality, appropriateness, or utilization of the chiropractic services rendered to the patient or the conduct of the chiropractor.

SB275,15,2 (3) Civil liability. A member of a peer review panel is immune from civil liability for a finding, evaluation, recommendation, or other action he or she makes or takes while performing a peer review under this section. This subsection does not apply if the member of the peer review panel acts in fraud, conspiracy, or malice.

SB275,15,5 (4) Insurance coverage. No finding, evaluation, or recommendation reached by a peer reviewer may be used to determine whether insurance coverage or reimbursement is appropriate.

SB275,15,7 (5) Sunset. This section does not apply after the first day of the 30th month beginning after the effective date of this subsection .... [revisor inserts date].

SB275, s. 17 Section 17. 446.04 (6), (7), (8), (9), (10) and (11) of the statutes are created to read: