SB269: Bill Text

Within three days after receiving the notice from the insured, the insurer must send to the independent review organization all of the information that it used in making the determination in the internal grievance procedure. No later than five days after receiving that information, the independent review organization may request more information from either or both parties, who have five more days in which to supply the requested information. The independent review organization may consider, however, any other relevant information, and any information that a party provides to the independent review organization must also be provided to the other party. Within 30 days after the expiration of all relevant time limits in the matter, the independent review organization must make a determination on the basis of the written information submitted by the parties. If an expedited review is required because of the insured's medical condition, all specified time limits are shortened, and the independent review organization must make a determination within 72 hours after the expiration of all relevant time limits in the matter. The bill specifies certain review standards for independent review organizations, including under what circumstances treatment that was considered experimental by the insurer issuing the health benefit plan must be covered. The decision at the conclusion of an independent review, which is binding on the insured and the insurer, must be in writing and served on both parties.

The bill contains prohibitions aimed at avoiding conflicts of interest for independent review organizations, such as prohibiting an independent review organization from owning, controlling or being a subsidiary of a health benefit plan or an association of health benefit plans. The bill also provides independent review organizations and clinical peer reviewers with immunity from liability for decisions made in independent reviews.

The bill requires the commissioner to promulgate rules relating to such topics as the application procedures and standards for certification and recertification of independent review organizations, additional procedures and processes that independent review organizations must use in independent reviews, standards for the practices and conduct of independent review organizations and additional standards related to conflicts of interest. The commissioner must also approve, on the basis of reasonableness, fees that independent review organizations charge for conducting independent reviews.

Finally, the bill requires the commissioner to determine when at least one independent review organization has been certified that is able to effectively provide the independent reviews required under the bill. When the commissioner makes that determination, the commissioner must publish a notice in the Wisconsin Administrative Register that specifies a date that is two months after the determination is made. That date is the date on which the independent review procedure must begin operating.

For further information see the state and local 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:

SB269, s. 1 Section 1. 40.51 (8) of the statutes is amended to read:

SB269,3,5 40.51 (8) Every health care coverage plan offered by the state under sub. (6) shall comply with ss. 631.89, 631.90, 631.93 (2), 632.72 (2), 632.746 (1) to (8) and (10), 632.747, 632.748, 632.83, 632.835, 632.85, 632.853, 632.855, 632.87 (3) to (5), 632.895 (5m) and (8) to (13) and 632.896.

SB269, s. 2 Section 2. 40.51 (8m) of the statutes is amended to read:

SB269,4,4 40.51 (8m) Every health care coverage plan offered by the group insurance board under sub. (7) shall comply with ss. 632.746 (1) to (8) and (10), 632.747, 632.748, 632.83, 632.835, 632.85, 632.853, 632.855 and 632.895 (11) to (13).

SB269, s. 3 Section 3. 111.91 (2) (r) of the statutes is created to read:

SB269,4,8 111.91 (2) (r) The requirements related to internal grievance procedures under s. 632.83 and independent review of certain health benefit plan determinations under s. 632.835.

SB269, s. 4 Section 4. 600.01 (2) (b) of the statutes is amended to read:

SB269,4,11 600.01 (2) (b) Group or blanket insurance described in sub. (1) (b) 3. and 4. is not exempt from ss. 632.745 to 632.749, 632.83 or 632.835 or ch. 633 or 635.

SB269, s. 5 Section 5. 601.31 (1) (Lp) of the statutes is created to read:

SB269,4,14 601.31 (1) (Lp) For certifying as an independent review organization under s. 632.835, $400.

SB269, s. 6 Section 6. 601.31 (1) (Lr) of the statutes is created to read:

SB269,4,17 601.31 (1) (Lr) For each biennial recertification as an independent review organization under s. 632.835, $100.

SB269, s. 7 Section 7. 601.42 (4) of the statutes is amended to read:

SB269,5,5 601.42 (4) Replies. Any officer, manager or general agent of any insurer authorized to do or doing an insurance business in this state, any person controlling or having a contract under which the person has a right to control such an insurer, whether exclusively or otherwise, any person with executive authority over or in charge of any segment of such an insurer's affairs, any individual practice association or officer, director or manager of an individual practice association, any insurance agent or other person licensed under chs. 600 to 646, any provider of services under a continuing care contract, as defined in s. 647.01 (2), any independent review organization certified or recertified under s. 632.835 (4) or any health care provider, as defined in s. 655.001 (8), shall reply promptly in writing or in other designated form, to any written inquiry from the commissioner requesting a reply.

SB269, s. 8 Section 8. 609.15 (title) and (1) (intro.) of the statutes are repealed.

SB269, s. 9 Section 9. 609.15 (1) (a) of the statutes is renumbered 632.83 (2) (a) and amended to read:

SB269,5,12 632.83 (2) (a) Establish and use an internal grievance procedure that is approved by the commissioner and that complies with sub. (2) (3) for the resolution of enrollees' insureds' grievances with the limited service health organization, preferred provider plan or managed care health benefit plan.

SB269, s. 10 Section 10. 609.15 (1) (b) of the statutes is renumbered 632.83 (2) (b) and amended to read:

SB269,5,16 632.83 (2) (b) Provide enrollees insureds with complete and understandable information describing the internal grievance procedure under par. (a).

SB269, s. 11 Section 11. 609.15 (1) (c) of the statutes is renumbered 632.83 (2) (c).

SB269, s. 12 Section 12. 609.15 (2) (intro.) of the statutes is renumbered 632.83 (3) (intro.) and amended to read:

SB269,5,21 632.83 (3) (intro.) The internal grievance procedure established under sub. (1) (2) (a) shall include all of the following elements:

SB269, s. 13 Section 13. 609.15 (2) (a) of the statutes is renumbered 632.83 (3) (a) and amended to read:

SB269,5,25 632.83 (3) (a) The opportunity for an enrollee insured to submit a written grievance in any form.

SB269, s. 14 Section 14. 609.15 (2) (b) of the statutes is renumbered 632.83 (3) (b) and amended to read:

SB269,6,6 632.83 (3) (b) Establishment of a grievance panel for the investigation of each grievance submitted under par. (a), consisting of at least one individual authorized to take corrective action on the grievance and at least one enrollee insured other than the grievant, if an enrollee insured is available to serve on the grievance panel.

SB269, s. 15 Section 15. 609.15 (2) (c) of the statutes is renumbered 632.83 (3) (c).

SB269, s. 16 Section 16. 609.15 (2) (d) of the statutes is renumbered 632.83 (3) (d).

SB269, s. 17 Section 17. 609.15 (2) (e) of the statutes is renumbered 632.83 (3) (e).

SB269, s. 18 Section 18. 609.655 (4) (b) of the statutes is amended to read:

SB269,6,18 609.655 (4) (b) Upon completion of the review under par. (a), the medical director of the managed care plan shall determine whether the policy or certificate will provide coverage of any further treatment for the dependent student's nervous or mental disorder or alcoholism or other drug abuse problems that is provided by a provider located in reasonably close proximity to the school in which the student is enrolled. If the dependent student disputes the medical director's determination, the dependent student may submit a written grievance under the managed care plan's internal grievance procedure established under s. 609.15 632.83.

SB269, s. 19 Section 19. 632.83 of the statutes is created to read:

SB269,6,24 632.83 Internal grievance procedure. (1) In this section, "health benefit plan" has the meaning given in s. 632.745 (11), except that "health benefit plan" includes the coverage specified in s. 632.745 (11) (b) 10. and includes a policy, certificate or contract under s. 632.745 (11) (b) 9. that provides only limited-scope dental or vision benefits.

SB269,6,25 (2) Every insurer that issues a health benefit plan shall do all of the following:

SB269, s. 20 Section 20. 632.835 of the statutes is created to read:

SB269,7,3 632.835 Independent review of adverse and experimental treatment determinations. (1) Definitions. In this section:

SB269,7,5 (a) "Adverse determination" means a determination by or on behalf of an insurer that issues a health benefit plan to which all of the following apply:

SB269,7,7 1. An admission to a health care facility, the availability of care, the continued stay or other treatment that is a covered benefit has been reviewed.

SB269,7,10 2. Based on the information provided, the treatment under subd. 1. does not meet the health benefit plan's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness.

SB269,7,13 3. Based on the information provided, the insurer that issued the health benefit plan reduced, denied or terminated the treatment under subd. 1. or payment for the treatment under subd. 1.

SB269,7,16 4. Subject to sub. (5) (c), the amount of the reduction or the cost or expected cost of the denied or terminated treatment or payment exceeds, or will exceed during the course of the treatment, $500.

SB269,7,19 (b) "Experimental treatment determination" means a determination by or on behalf of an insurer that issues a health benefit plan to which all of the following apply:

SB269,7,20 1. A proposed treatment has been reviewed.

SB269,7,22 2. Based on the information provided, the treatment under subd. 1. is determined to be experimental under the terms of the health benefit plan.

SB269,7,25 3. Based on the information provided, the insurer that issued the health benefit plan denied the treatment under subd. 1. or payment for the treatment under subd. 1.

SB269,8,2 4. Subject to sub. (5) (c), the cost or expected cost of the denied treatment or payment exceeds, or will exceed during the course of the treatment, $500.

SB269,8,4 (c) "Health benefit plan" has the meaning given in s. 632.745 (11), except that "health benefit plan" includes the coverage specified in s. 632.745 (11) (b) 10.

SB269,8,6 (d) "Treatment" means a medical service, diagnosis, procedure, therapy, drug or device.

SB269,8,11 (2) Review requirements; who may conduct. (a) Every insurer that issues a health benefit plan shall establish an independent review procedure whereby an insured under the health benefit plan, or his or her authorized representative, may request and obtain an independent review of an adverse determination or an experimental treatment determination made with respect to the insured.

SB269,8,19 (b) Whenever an adverse determination or an experimental treatment determination is made, the insurer involved in the determination shall provide notice to the insured of the insured's right to obtain the independent review required under this section, how to request the review and the time within which the review must be requested. The notice shall include a current listing of independent review organizations certified under sub. (4). An independent review under this section may be conducted only by an independent review organization certified under sub. (4) and selected by the insured.

SB269,8,25 (c) Except as provided in par. (d), an insured must exhaust the internal grievance procedure under s. 632.83 before the insured may request an independent review under this section. Except as provided in sub. (9), an insured who uses the internal grievance procedure must request an independent review as provided in sub. (3) (a) within 4 months after the insured receives notice of the disposition of his or her grievance under s. 632.83 (3) (d).

SB269,9,3 (d) An insured is not required to exhaust the internal grievance procedure under s. 632.83 before requesting an independent review if any of the following apply:

SB269,9,5 1. The insured and the insurer agree that the matter may proceed directly to independent review under sub. (3).

SB269,9,12 2. Along with the notice to the insurer of the request for independent review under sub. (3) (a), the insured submits to the independent review organization selected by the insured a request to bypass the internal grievance procedure under s. 632.83 and the independent review organization determines that the health condition of the insured is such that requiring the insured to use the internal grievance procedure before proceeding to independent review would jeopardize the life or health of the insured or the insured's ability to regain maximum function.

SB269,9,24 (3) Procedure. (a) To request an independent review, an insured or his or her authorized representative shall provide timely written notice of the request for independent review, and of the independent review organization selected, to the insurer that made or on whose behalf was made the adverse or experimental treatment determination. The insurer shall immediately notify the commissioner and the independent review organization selected by the insured of the request for independent review. The insured or his or her authorized representative must pay a $50 fee to the independent review organization. If the insured prevails on the review, in whole or in part, the entire amount paid by the insured or his or her authorized representative shall be refunded by the insurer to the insured or his or her authorized representative. For each independent review in which it is involved, an insurer shall pay a fee to the independent review organization.

SB269,10,3 (b) Within 3 business days after receiving written notice of a request for independent review under par. (a), the insurer shall submit to the independent review organization copies of all of the following:

SB269,10,5 1. Any information submitted to the insurer by the insured in support of the insured's position in the internal grievance under s. 632.83.

SB269,10,7 2. The contract provisions or evidence of coverage of the insured's health benefit plan.

SB269,10,9 3. Any other relevant documents or information used by the insurer in the internal grievance determination under s. 632.83.

SB269,10,15 (c) Within 5 business days after receiving the information under par. (b), the independent review organization shall request any additional information that it requires for the review from the insured or the insurer. Within 5 business days after receiving a request for additional information, the insured or the insurer shall submit the information or an explanation of why the information is not being submitted.

SB269,10,18 (d) An independent review under this section may not include appearances by the insured or his or her authorized representative, any person representing the health benefit plan or any witness on behalf of either the insured or the insurer.

SB269,11,3 (e) In addition to the information under pars. (b) and (c), the independent review organization may accept for consideration any typed or printed, verifiable medical or scientific evidence that the independent review organization determines is relevant, regardless of whether the evidence has been submitted for consideration at any time previously. The insurer and the insured shall submit to the other party to the independent review any information submitted to the independent review organization under this paragraph and pars. (b) and (c). If, on the basis of any additional information, the insurer reconsiders the insured's grievance and determines that the treatment that was the subject of the grievance should be covered, the independent review is terminated.

SB269,11,11 (f) If the independent review is not terminated under par. (e), the independent review organization shall, within 30 business days after the expiration of all time limits that apply in the matter, make a decision on the basis of the documents and information submitted under this subsection. The decision shall be in writing, signed on behalf of the independent review organization and served by personal delivery or by mailing a copy to the insured or his or her authorized representative and to the insurer. A decision of an independent review organization is binding on the insured and the insurer.

SB269,11,16 (g) If the independent review organization determines that the health condition of the insured is such that following the procedure outlined in pars. (b) to (f) would jeopardize the life or health of the insured or the insured's ability to regain maximum function, the procedure outlined in pars. (b) to (f) shall be followed with the following differences:

SB269,11,18 1. The insurer shall submit the information under par. (b) within one day after receiving the notice of the request for independent review under par. (a).

SB269,11,21 2. The independent review organization shall request any additional information under par. (c) within 2 business days after receiving the information under par. (b).

SB269,11,24 3. The insured or insurer shall, within 2 days after receiving a request under par. (c), submit any information requested or an explanation of why the information is not being submitted.

SB269,12,3 4. The independent review organization shall make its decision under par. (f) within 72 hours after the expiration of the time limits under this paragraph that apply in the matter.

SB269,12,6 (3m) Standards for decisions. (a) A decision of an independent review organization regarding an adverse determination must be consistent with the terms of the health benefit plan under which the adverse determination was made.

SB269,12,11 (b) A decision of an independent review organization regarding an experimental treatment determination is limited to a determination of whether the proposed treatment is experimental. The independent review organization shall determine that the treatment is not experimental and find in favor of the insured only if the independent review organization finds all of the following:

SB269,12,14 1. The treatment has been approved by the federal food and drug administration, if the treatment is subject to the approval of the federal food and drug administration.

SB269,12,16 2. Medically and scientifically accepted evidence clearly demonstrates that the treatment meets all of the following criteria:

SB269,12,17 a. The treatment is proven safe.

SB269,12,18 am. The treatment is proven effective for the insured's condition.

SB269,12,20 b. The treatment can be expected to produce greater benefits than the standard treatment without posing a greater adverse risk to the insured.

SB269,12,22 c. The treatment meets the coverage terms of the health benefit plan and is not specifically excluded under the terms of the health benefit plan.

SB269,13,3 (4) Certification of independent review organizations. (a) The commissioner shall certify independent review organizations. An independent review organization must demonstrate to the satisfaction of the commissioner that it is unbiased, as defined by the commissioner by rule. An organization certified under this paragraph must be recertified on a biennial basis to continue to provide independent review services under this section.

SB269,13,7 (ag) An independent review organization shall have in operation a quality assurance mechanism to ensure the timeliness and quality of the independent reviews, the qualifications and independence of the clinical peer reviewers and the confidentiality of the medical records and review materials.

SB269,13,13 (ap) An independent review organization shall establish reasonable fees that it will charge for independent reviews and shall submit its fee schedule to the commissioner for a determination of reasonableness and for approval. An independent review organization may not change any fees approved by the commissioner more than once per year and shall submit any proposed fee changes to the commissioner for approval.

SB269,13,18 (b) An organization applying for certification or recertification as an independent review organization shall pay the applicable fee under s. 601.31 (1) (Lp) or (Lr). Every organization certified or recertified as an independent review organization shall file a report with the commissioner in accordance with rules promulgated under sub. (5) (a) 4.

SB269,13,22 (c) The commissioner may examine, audit or accept an audit of the books and records of an independent review organization as provided for examination of licensees and permittees under s. 601.43 (1), (3), (4) and (5), to be conducted as provided in s. 601.44, and with costs to be paid as provided in s. 601.45.

SB269,14,6 (d) The commissioner may revoke, suspend or limit in whole or in part the certification of an independent review organization, or may refuse to recertify an independent review organization, if the commissioner finds that the independent review organization is unqualified or has violated an insurance statute or rule or a valid order of the commissioner under s. 601.41 (4), or if the independent review organization's methods or practices in the conduct of its business endanger, or its financial resources are inadequate to safeguard, the legitimate interests of consumers and the public. The commissioner may summarily suspend an independent review organization's certification under s. 227.51 (3).