SB599: Bill Text

SB599,12,4 (j) The amount by which estimated payments by government payers under s. 196.999 (1) (a) exceed actual payments.

SB599,12,6 (k) Financial incentives. The commission shall, by rule, allow financial incen tives as additional financial requirements for efficiently operated hospitals.

SB599,12,19 (2) Hospitals may collect revenue from sources other than patients, including gifts and grants, investment income or income from activities incidental to patient care. Revenues from endowment funds or donor-restricted gifts to provide services for designated patients shall offset the cost of those services. No revenue from gener al endowment funds or unrestricted gifts may be used to offset operating expenses except that revenue from these funds or gifts may be used to offset interest expenses. Revenues received to finance special projects or wages paid to special project em ployes shall offset the cost of patient services. Revenues from meals sold to visitors or employes, from drugs sold to persons who are not patients, from the operation of gift shops or parking lots or from the provision of televisions, radios or telephones to patients shall offset the cost of these services, subject to the limitation that the amount of revenue offset from any of these services may not exceed the cost of the service.

SB599,12,25 (3) Purchase discounts, the amount by which actual payments by government payers exceed estimated payments under s. 196.999 (1) (a) and allowances and re funds of expenses shall be subtracted from the calculation of financial requirements under sub. (1). Revenues from invested funds shall also be subtracted from the cal culation of financial requirements but may not offset an amount that exceeds the hospital's interest expenses.

SB599,13,5 (4) After the sale of a hospital, the commission may calculate depreciation un der sub. (1) based on a revaluation of the hospital's plant and equipment in order to determine its reasonable value. The revaluation shall be based on appraisals con ducted by 2 independent appraisers, one of whom shall be selected by the hospital and one by the commission. The hospital shall pay the cost of both appraisals.

SB599,13,8 196.996 Standards for decision making. The commission and its staff shall review and evaluate each hospital's proposed financial requirements and rate re quest in light of a variety of standards for decision making, including:

SB599,13,11 (1) The need to reduce the rate of hospital cost increases while preserving the quality of health care in all parts of the state and taking into account the financial viability of economically and efficiently operated hospitals.

SB599,13,15 (2) Comparisons with prudently administered hospitals of similar size or pro viding similar services that offer quality health care with sufficient staff. In classify ing hospitals according to size and services, the commission shall consider volume, intensity and educational programs and special services provided by hospitals.

SB599,13,17 (3) A variety of cost-related trend factors based on nationally or regionally rec ognized economic models.

SB599,13,18 (4) The special circumstances of rural hospitals and teaching hospitals.

SB599,13,20 (5) The past budget and rate experiences of the hospital that submits the rate request.

SB599,13,22 (6) Findings of the utilization review program under s. 196.9993 (3) concerning the hospital that submits the rate request.

SB599,13,24 196.997 Initial determinations. (1) After reviewing a hospital's proposed financial requirements, the commission may disallow any of the following:

SB599,14,2 (a) Costs associated with medical services that a utilization review program un der s. 196.9993 determines are medically unnecessary or inappropriate.

SB599,14,10 (b) Forty percent of the amount by which patient revenue generated by the hos pital during its previous fiscal year exceeds 104% of the hospital's budgeted patient revenue for that year, if the hospital's annual gross patient revenue is less than $5,000,000, adjusted as provided in s. 196.9995, or exceeds 102% of the hospital's budgeted patient revenue for that year, if the hospital's annual gross patient revenue equals or exceeds $5,000,000, adjusted as provided in s. 196.9995. The commission shall, by rule, establish a procedure under which hospitals whose variable costs ex ceed 65% are subject to a lesser disallowance under this paragraph.

SB599,14,12 (c) Rate overcharges of the hospital that occurred in a prior year and for which payers have not been reimbursed.

SB599,14,16 (d) The amount by which incremental expenses that are associated with the cost of a capital project exceed 105% of the expenses projected in the hospital's ap plication for approval of the capital project. This paragraph does not apply if any of the following applies:

SB599,14,18 1. The hospital demonstrates to the satisfaction of the commission that the ex cess was due to conditions beyond its control.

SB599,14,19 2. The excess occurs more than 3 years after completion of the capital project.

SB599,14,20 (e) Costs that the commission determines under s. 196.996 are unreasonable.

SB599,15,2 (f) Wages that the record demonstrates to be excessive. In making determina tions under this paragraph, the commission shall consider the wage levels offered by hospitals located in a relevant geographic area surrounding the hospital that sub mitted the rate request as well as by hospitals of similar size or providing similar ser vices. In addition, the commission shall consider the hospital's ability to attract ade quate staff and the wage trends in nonregulated, related sectors of the Wisconsin economy.

SB599,15,3 (g) Amounts paid for services regulated under s. 111.18 (2) (a) 1.

SB599,15,10 (2) (a) After reviewing the hospital's financial requirements and rate request, the commission staff shall suggest any disallowances authorized under sub. (1) and shall submit its rate recommendations to the hospital and commission. If it considers the hospital proposal unacceptable, the commission staff shall explain to the hospital what facts and standards cause it to disagree and shall submit alternate recommen dations. A hospital that fails to accept any part of the commission staff's recommen dations shall request a settlement conference under s. 196.998.

SB599,15,16 (b) 1. Except as provided in subd. 2., the commission staff shall submit its rec ommendations under par. (a) within 60 days after the date that review commences under s. 196.994 (1), even if the commission staff determines that the data provided by the hospital for a scheduled review are incomplete. The commission staff may, however, recommend a disallowance or an alternate rate, including no rate increase, on the grounds of insufficient data.

SB599,15,19 2. a. The commission staff may extend the deadline specified in subd. 1. by 15 days if it determines that the rate request submitted involves particularly complex issues of fact.

SB599,15,21 b. The deadline specified in subd. 1. may be extended with the consent of the hospital and the commission staff.

SB599,16,5 196.998 Review of determinations. (1) Any hospital that disputes any part of the recommendations of the commission staff under s. 196.997 shall, within 10 days after the recommendations are submitted under s. 196.997 (2), request a settle ment conference between its representatives and the commission staff for the pur pose of resolving their differences or defining more precisely the nature of their dif ferences. The chairperson of the commission, or a commissioner designated by the chairperson, shall preside over each settlement conference. Within 20 days after the hospital requests a settlement conference, the settlement conference shall be com pleted.

SB599,16,13 (2) Any hospital that is dissatisfied with the results of its settlement conference under sub. (1) is entitled to a hearing before the commission under sub. (3) if it sub mits a timely request. Each request for a hearing shall be submitted to the commis sion within 10 days after the completion of the settlement conference. The hospital may present testimony based on any standard for decision making listed in s. 196.996. All questions of fact shall be determined without ascribing greater weight to evidence presented by commission staff than to evidence presented by any other party solely due to its presentation by the staff.

SB599,16,19 (3) (a) Informal hearings shall be conducted before at least 2 commissioners. Sworn testimony is required only if the presiding commissioners so specify. The com missioners may establish time limits for cross-examination of witnesses and rebut tal arguments and may limit the number of persons who may appear at the hearing. Rules of evidence, except the rule that evidence be relevant to the issues presented, do not apply to informal hearings.

SB599,17,2 (b) A hospital that requests an informal hearing shall present the reasons sup porting its proposed rate increase and financial requirements. Commission staff shall respond by explaining its disagreement and its alternate recommendations. Within the time limits specified in par. (a), the hospital, parties to the review and commission staff may each cross-examine witnesses and rebut arguments pres ented. The hospital, parties to the review and the commission staff may use outside experts to present their position. The presiding commissioners may impose an over all time limit on the length of the hearing.

SB599,17,4 (c) The commission may, by order, conduct a class 1 contested case proceeding under ch. 227 in place of an informal hearing under pars. (a) and (b).

SB599,17,9 (5) The commission shall keep a complete record of all hearings and investiga tions conducted under sub. (3) using a stenographic, electronic or other method to re cord all testimony presented. The commission shall provide a transcribed, certified copy of all or any part of this record on the request of any party to a hearing or inves tigation, but may charge the requester for the costs involved.

SB599,17,14 (6) (a) Any person may request a hearing under s. 227.44, regardless of whether any other hearing is authorized by law or is authorized at the discretion of the com mission or whether any other proceeding is authorized by rule of the commission, subject to the limitation that no person may receive more than one contested case hearing concerning a particular act or failure to act by the commission.

SB599,17,16 (b) Notwithstanding par. (a), no person may request a hearing under s. 227.44 pertaining to the subject matter of a hearing under sub. (3).

SB599,17,18 (c) The right to a hearing under s. 227.44, as specified in this subsection, applies only to subject matter pertaining to this subchapter.

SB599,18,6 196.999 Commission orders. (1) (a) The commission shall determine allow able financial requirements under s. 196.995 and disallowances under s. 196.997. From the difference between these amounts, the commission shall subtract the hos pital's estimated relief payments and medical assistance payments under ch. 49 and medicare payments under 42 USC 1395 to 1395ccc, unless the commission deter mines that the hospital's estimates are incorrect, in which case the commission shall subtract its own estimates of the hospital's relief, medical assistance and medicare payments. The commission shall, by order, establish maximum rates that allow the hospital to generate revenue sufficient to provide this remainder. The commission shall, by rule, establish acceptable methods of estimating payments by relief, medi cal assistance and medicare under this paragraph. Each hospital shall choose one of these methods and use it consistently unless the commission authorizes the hospi tal to change its method.

SB599,18,15 (b) Unless the hospital requests a hearing under s. 196.998 (3), the commission shall issue its order under par. (a) within 15 days after the commission staff submits its recommendations or, if the hospital requests a settlement conference under s. 196.998 (1), within 15 days after the commission determines that the hospital will not seek a hearing following the conclusion of the settlement conference. If the hospi tal disputes only part of the recommendations of the commission staff, the commis sion may establish maximum rates under par. (a) concerning the recommendations with which the hospital agrees prior to the conclusion of the hearing under s. 196.998 (3).

SB599,18,21 (c) If the hospital disputes the recommendations of the commission staff and a hearing is held under s. 196.998 (3) (c), the commission shall establish by order maximum rates for the hospital's year under review at the conclusion of the hearing. If the commission conducts an informal hearing under s. 196.998 (3) (a) and (b), it shall issue its order within 50 days after the date on which the hospital requested the hearing.

SB599,18,25 (d) 1. The commission shall state findings of fact and the reasons supporting each order that it issues concerning financial requirements and rates. If the commis sion denies any part of a rate request, it shall also specify, as part of its order, any financial requirements that it has disallowed.

SB599,19,21 2. Any hospital may apply an increase in its rates selectively, if the aggregate increase in its rates does not exceed the amount authorized by the commission. Prior to instituting its rate increase, the hospital shall explain to the commission its meth od of applying the rate increase and allow the commission 5 working days, as defined in s. 227.01 (14), to determine if the aggregate increase in rates exceeds the autho rized amount. Failure to disapprove the hospital's method of applying the rate in crease within this period constitutes an approval. If the commission approves the hospital's method of applying the rate increase, the commission may not challenge the method prior to the date of a succeeding review under s. 196.994 (1) except as pro vided in sub. (4) (a). If the commission disapproves the hospital's method of applying the rate increase, it shall recommend an alternate method. If the hospital fails to modify its method of applying the rate increase, the commission may challenge the method in circuit court. In addition to any other remedy the court may impose under s. 196.9994, if the court finds that the hospital's method generates an aggregate in crease in the hospital's rates that is inconsistent with the amount authorized by the commission, the hospital shall forfeit an amount equal to 50% of the amount over charged and shall comply with the alternate method recommended by the commis sion or with any other method ordered by the court that the court finds more consis tent with the commission's order. No hospital may change a method of applying its rate increase that has received the commission's approval without submitting the changes to the commission for its approval under this subdivision.

SB599,20,2 3. Any hospital receiving a rate increase that may only commence between the 2nd and 7th months of its fiscal year may make an adjustment to the rate increase, that applies to that fiscal year only, in order to generate an amount of revenue equal to the amount that would have been generated if the hospital could have commenced the rate increase beginning with the first month of its fiscal year.

SB599,20,6 (e) Except as provided in s. 196.9991, even if a party seeks judicial review of a commission order, the affected hospital may continue to bill payers at the rates es tablished by the commission. No hospital that bills payers under this paragraph ad versely affects its right to contest the rates established by the commission.

SB599,20,9 (1m) Notwithstanding sub. (1) (b) and ss. 196.994 (1), 196.997 (2) and 196.998, at the request of a hospital the commission may waive the procedures for review of a rate request and issue an interim order in an emergency.

SB599,20,12 (2) The commission shall determine the rates of each hospital independently using criteria specified in s. 196.996, but in making these determinations the com mission may use methods of identifying similar hospitals.

SB599,20,20 (3) The commission may promulgate rules establishing a system that defines rates as aggregate charges based on case mix measurements if the commission sub mits its proposed system to the joint committee on finance under s. 13.10, receives that committee's approval and holds a public hearing prior to promulgating its rules. Such a system may not take effect prior to July 1, 1997, shall be consistent with the standard under s. 196.996 (1), shall take into account the reasonable financial re quirements of hospitals and shall ensure quality of care and a reasonable cost to pa tients.

SB599,20,21 (4) The commission may not:

SB599,20,25 (a) Reduce rates that it has established, prior to the date the commission sched ules a succeeding review under s. 196.994 (1), unless the hospital misstated any ma terial fact at a prior rate-setting proceeding. Projections on the volume of hospital services utilized do not constitute material facts under this paragraph.

SB599,21,2 (b) During a succeeding review under s. 196.994 (1), reduce rates from levels that it has previously established, except in any of the following situations:

SB599,21,4 1. The hospital implements an unauthorized increase in its approved rates, un less the increase is trivial.

SB599,21,6 2. The hospital uses the funds that it has prospectively accumulated for an au thorized capital project for purposes other than the authorized project.

SB599,21,8 4. The hospital's actual total revenue for its fiscal year exceeds it actual total financial requirements by more than 10%.

SB599,21,12 (c) Interfere directly in the personal or decision-making relationships between a patient and the patient's physician, except as provided in ss. 196.9993 and 196.9994 (2). This paragraph does not limit the commission's ability to make deter minations under sub. (1) (a) or s. 196.997.

SB599,21,15 (d) Control directly the volume or intensity of hospital utilization, except as provided in ss. 196.9993 and 196.9994 (2). This paragraph does not limit the commis sion's ability to make determinations under sub. (1) (a) or s. 196.997.

SB599,21,19 (e) Restrict the freedom of patients to receive care at a hospital consistent with their religious preferences or request a hospital that is affiliated with a religious group to act in a manner contrary to the mission and philosophy of the religious group.

SB599,21,22 (f) Restrict directly the freedom of hospitals to exercise management decisions in complying with the rates established by the commission, unless a hospital agrees to a condition attached to the establishment of particular rates.

SB599,21,24 (g) Require the submission of unrelated financial data from religious groups affiliated with a hospital.

SB599,22,3 196.9991 Injunctions of commission orders. No injunction may be issued to suspend or stay enforcement of an order of the commission unless all of the follow ing occur:

SB599,22,7 (1) All parties to the proceeding from which the commission's order was issued are notified of the petition seeking an injunction, are given an opportunity to appear at a hearing prior to the issuance of the injunction and are made parties to the pro ceeding in circuit court.

SB599,22,12 (2) The party seeking the injunction enters into an undertaking by at least 2 sureties at a level that the circuit court finds sufficient to guarantee the payment of all damages the hospital may sustain by delaying the effect of the commission's order. This subsection does not apply to a hospital that was a party to the proceeding from which the commission's order was issued.

SB599,22,15 196.9992 Expedited review, expedited cases and exempt hospitals. (1) The commission may promulgate rules under which hospitals meeting specific crite ria receive expedited review of rate requests under this subchapter.

SB599,22,18 (2) (a) A hospital whose gross annual patient revenue is less than $10,000,000, adjusted as provided in s. 196.9995, for the hospital's last fiscal year is eligible to re ceive automatic approval of its rate request if it meets all of the following criteria:

SB599,22,20 1. The commission has conducted a complete review of the hospital's rates and has set the hospital's rates in a preceding year.

SB599,22,23 2. The hospital requests a rate increase that is less than an inflationary index consisting of the average of the consumer price index and the hospital market basket index.

SB599,23,3 (b) Any hospital that receives automatic approval of its rate request under this subsection shall publish as a class 1 notice under ch. 985, in one or more newspapers likely to give notice to its patients and payers, a list of the price adjustments it is mak ing to 100 of its charge elements as specified by the commission. The hospital shall publish this notice prior to implementing its rate increase.

SB599,23,5 (c) The commission may, by rule, extend automatic approval status under this subsection to other hospitals.

SB599,23,10 (2m) The commission may grant hospitals whose gross annual patient revenue is less than $10,000,000, adjusted as provided in s. 196.9995, a rate increase that takes effect over a 2-year period with an automatic escalation clause taking effect at the end of the first year. A hospital that receives a 2-year rate increase is not re quired to request a rate increase at the end of the first year.

SB599,23,12 (3) Any judicial proceeding affecting a rule or decision of the commission shall be heard and determined as expeditiously as possible.

SB599,23,16 196.9993 Utilization review program. (1) The commission shall approve an all-patient utilization review program for each hospital that shall conform to re quirements of federal regulations on utilization review programs. The commission may evaluate these programs as part of its monitoring functions under s. 196.994 (3).

SB599,23,22 (2) The commission shall contract with one or more independent utilization re view programs to develop review standards, and the commission may contract with any person to monitor implementation of these programs by hospitals and to perform peer review functions for hospitals that fail to meet the performance standards adopted by the commission. The commission may not contract with state agencies, other than the University of Wisconsin System, under this subsection.

SB599,24,2 (3) Each utilization review program the commission approves shall include a general summary of utilization within the hospital. These programs need not other wise be identical but shall meet minimum standards established by the commission and shall do all of the following:

SB599,24,4 (a) Evaluate the medical necessity or appropriateness of care relative to admis sions, lengths of stay and ancillary services.

SB599,24,7 (b) Report to the commission, in conjunction with each hospital's submission of proposed financial requirements, any findings that it has made regarding unnec essary or inappropriate medical care utilization and associated costs.

SB599,24,12 196.9994 Enforcement. (1) (a) Until the commission establishes different rates under this subchapter, no hospital may charge any payer an amount exceeding the rates established as of the effective date of this paragraph .... [revisor inserts date]. No hospital may charge any payer an amount exceeding the rates established under this subchapter.

SB599,24,19 (b) The attorney general may seek a judicial remedy to enforce compliance with par. (a) if the attorney general first notifies the hospital and provides the hospital a reasonable time to correct a violation. The commission may seek a judicial remedy to enforce compliance with any statutory requirement or with any rule or order of the commission if it first notifies the hospital and provides the hospital a reasonable time to correct a violation. The commission shall commence any action under this para graph in the circuit court for the county in which the hospital is located.

SB599,24,23 (c) Any court that finds an intentional failure to comply with the rates under this subsection may impose a forfeiture of up to $5,000. Each week that a hospital continues its intentional failure to comply with the rates constitutes a separate viola tion.

SB599,25,4 (2) Neither a hospital nor a physician may be paid for a service that a utiliza tion review program under s. 196.9993 determines is medically unnecessary or inap propriate. If the hospital or physician has already been paid, the hospital or physi cian shall reimburse the payer within 30 days. The commission may commence an action to enforce this subsection in the circuit court for the county in which the hospi tal is located.

SB599,25,7 (3) Any court with jurisdiction over an action brought under this section may adopt remedies that it finds necessary to enforce compliance. Remedies under this section apply notwithstanding the existence or pursuit of any other remedy.

SB599,25,10 (4) Any person who intentionally violates an order of a hearing examiner is sued under s. 227.46 (7) to protect trade secrets in a contested case brought under this subchapter shall forfeit $5,000.

SB599,25,14 196.9995 Annual adjustments. The limits on gross annual patient revenue in ss. 196.997 (1) (b) and 196.9992 (2) (a) (intro.) and (2m) shall be adjusted annually to reflect annual changes in the average of the consumer price index and the hospital market basket index.

SB599,25,15 196.9996 Assessments. (1) In this section:

SB599,25,18 (a) "Commercial insurance" includes a group or individual disability insurance policy, as defined in s. 632.895 (1) (a), an employer's self-insured health care plan and worker's compensation.

SB599,25,21 (b) "Deduction" means the portion of a charge that was incurred by a patient but was not received from 3rd-party payers or governmental or private payment. "Deduction" includes charity care but does not include bad debt.

SB599,25,23 (c) "Expense" means the cost of operation, including bad debt, that is charged to a hospital during the hospital's fiscal year.

SB599,26,2 (d) "Gross patient revenue" means the total charges to medicare, as defined in s. 49.498 (1) (f), the medical assistance program, other public programs, commercial insurance and other self-payers or nonpublic payers, that are generated by a hospi tal from inpatient and outpatient services.

SB599,26,4 (e) "Net income" means total revenue and nonoperating gains in excess of ex penses and nonoperating losses.

SB599,26,5 (f) "Net patient revenue" means gross patient revenue minus deductions.

SB599,26,7 (g) "Nonoperating gains" means gifts, donations, endowments, return on in vestments and any other gains that are not related to patient care.

SB599,26,10 (h) "Nonoperating losses" means state and federal corporate income and real estate taxes and other losses that are not directly related to patient care or hospital- related patient services.

SB599,26,13 (i) "Other public programs" include programs operated by or contracted for by county departments under s. 46.215, 46.22 or 46.23 and the relief program under ch. 49.