SB599: Bill Text

SB599,4,14 49.49 (2) (c) 1. A discount or other reduction in price obtained by a provider of services or other entity under chs. 46 to 51 and 58 and subch. II of ch. 196 if the reduc tion in price is properly disclosed and appropriately reflected in the costs claimed or charges made by the provider or entity under a medical assistance program.

SB599, s. 6 Section 6. 49.74 of the statutes, as affected by 1995 Wisconsin Act 27, is amended to read:

SB599,4,19 49.74 (title) Institutions subject to chapter chapters 150 and 196. Any institution created under the authority of s. 49.70, 49.71, 49.72 or 49.73 is subject to ch. 150 and subch. II of ch. 196.

SB599, s. 7 Section 7. 50.36 (1) of the statutes, as affected by 1995 Wisconsin Act 27, is amended to read:

SB599,5,8 50.36 (1) The department shall promulgate, adopt, amend and enforce such rules and standards for hospitals for the construction, maintenance and operation of the hospitals deemed necessary to provide safe and adequate care and treatment of the patients in the hospitals and to protect the health and safety of the patients and employes; and nothing contained herein shall pertain to a person licensed to practice medicine and surgery or dentistry. The building codes and construction standards of the department of development shall apply to all hospitals and the de partment may adopt additional construction codes and standards for hospitals, pro vided they are not lower than the requirements of the department of development. Except for the construction codes and standards of the department of development and except as provided in s. 50.39 (3) and subch. II of ch. 196, the department shall be the sole agency to adopt and enforce rules and standards pertaining to hospitals.

SB599, s. 8 Section 8. 146.37 (1g) of the statutes is amended to read:

SB599,5,25 146.37 (1g) Except as provided in s. 153.85, no person acting in good faith who participates in the review or evaluation of the services of health care providers or fa cilities or the charges for such services conducted in connection with any program organized and operated to help improve the quality of health care, to avoid improper utilization of the services of health care providers or facilities or to determine the rea sonable charges for such services, or who participates in the obtaining of health care information under ch. 153, or who participates in hospital rate-setting activities un der subch. II of ch. 196, is liable for any civil damages as a result of any act or omission by such person in the course of such review or evaluation. Acts and omissions to which this subsection applies include, but are not limited to, acts or omissions by peer review committees or hospital governing bodies in censuring, reprimanding, limiting or revoking hospital staff privileges or notifying the medical examining board under s. 50.36 or taking any other disciplinary action against a health care provider or facil ity and acts or omissions by a medical director, as defined in s. 146.50 (1) (j), in review ing the performance of emergency medical technicians or ambulance service provid ers.

SB599, s. 9 Section 9. 153.05 (4n) of the statutes is created to read:

SB599,6,4 153.05 (4n) The office shall provide the public service commission with in formation necessary for performance of duties of the public service commission under s. 196.9998 (16) (a) and as requested of the office by the public service commission.

SB599, s. 10 Section 10. Chapter 196 (title) of the statutes is amended to read:

SB599,6,6 CHAPTER 196

SB599,6,8 REGULATION OF PUBLIC UTILITIES service commission

SB599, s. 11 Section 11. Subchapter I (title) of chapter 196 [precedes 196.01] of the statutes is created to read:

SB599,6,11 chapter 196

SB599,6,12 subchapter I

SB599,6,13 regulation of public utilities

SB599, s. 12 Section 12. 196.01 (intro.) of the statutes is amended to read:

SB599,6,16 196.01 Definitions. (intro.) As used in this chapter subchapter and ch. 197, unless the context requires otherwise:

SB599, s. 13 Section 13. Subchapter II of chapter 196 [precedes 196.991] of the statutes is created to read:

SB599,6,19 Chapter 196

SB599,6,21 Subchapter II Hospital rate setting

SB599,6,22 196.991 Definitions. In this subchapter:

SB599,6,24 (1) "Capital expenditure limit" means the maximum amount of capital expen ditures that may be approved under s. 196.9998.

SB599,7,3 (1m) "Capital project" means a proposed capital expenditure that exceeds $1,000,000 or, if the purpose of converting to a new use or renovating part or all of a hospital, a proposed capital expenditure that exceeds $1,500,000.

SB599,7,4 (2) "Commission" means the public service commission.

SB599,7,5 (3) "Consumer price index" has the meaning given in s. 16.004 (8) (e) 1.

SB599,7,7 (4) "Hospital" has the meaning given in s. 50.33 (2), except that "hospital" does not include a center for the developmentally disabled, as defined in s. 51.01 (3).

SB599,7,10 (5) "Rates" means individual charges of a hospital for the services that it pro vides or, if authorized under s. 196.999 (3), the aggregate charges based on case mix measurements.

SB599,7,15 196.992 Prospective rate setting. Beginning on July 1, 1997, the commis sion shall establish and may regularly revise maximum hospital rates on a prospec tive basis. The commission shall publish biennial reports showing its proceedings, together with information necessary to describe the rate of hospital cost increases and the financial condition of hospitals.

SB599,7,16 196.993 Rule making. The commission shall promulgate all of the following:

SB599,7,18 (1) Rules that implement this subchapter. At least 2 commissioners must sign any rules that are promulgated to interpret s. 196.992.

SB599,7,20 (2) Rules that establish the rate for assessments that are authorized under s. 196.9996.

SB599,8,2 196.994 Requests for a rate change. (1) The commission shall create a schedule allowing each hospital to request rate changes annually, on or after the date the hospital receives its audited financial statements. The commission may schedule a review of the hospital's rates and revise the rates on its own initiative or at the request of any person when good cause is shown. A hospital may submit a rate request on or after the scheduled date.

SB599,8,11 (2) Within 10 days after it submits a rate request under sub. (1), the hospital shall publish a class 1 notice under ch. 985. If the hospital fails to submit a rate re quest by the date scheduled for a review under sub. (1), the commission shall publish a class 1 notice under ch. 985 within 10 days after the date scheduled for the review. This notice, whether published by the hospital or the commission, shall inform the public of the review, summarize the rate sought, if any, and state the process by which interested persons may become parties to the review. A person may become a party to the review only by notifying the commission in writing within 30 days after the date the notice is published.

SB599,8,21 (3) Each hospital shall submit its proposed financial requirements to the com mission at the same time that it submits a rate request. Except as provided in s. 196.999 (4) (g), each hospital shall provide the commission with the information that the commission determines is necessary to perform its responsibilities with respect to setting rates and monitoring established rates. Patient care and other organiza tions and hospital corporate affiliates that generate financial requirements of a hos pital under review shall also release to the commission financial or other statistical information related to the financial requirements that the commission determines is necessary to perform its responsibilities with respect to setting rates and monitor ing established rates.

SB599,8,23 (4) The commission may require hospitals to conform with a uniform reporting system.

SB599,8,25 (5) The commission shall establish and regularly publish a list of the 25 most heavily used charge elements for hospitals.

SB599,9,2 196.995 Financial requirements. (1) Financial requirements of each hospi tal that submits a rate request shall include:

SB599,9,10 (a) Necessary operating expenses, including wages, employe fringe benefits, purchased services, professional fees, repairs and maintenance, dietary and medical supplies, pharmaceuticals, utilities, insurance, standby costs and applicable taxes. Any amount representing the value of services performed by members of a religious order or other organized religious group may only be included if actually paid to members of the religious group and shall be equivalent to the amounts paid to em ployes for similar work. The commission may not use previously accumulated de preciation of capitalized assets to offset operating expenses.

SB599,9,16 (b) Interest expenses on debt incurred for capital or operating costs. Interest payments on debts incurred for capital costs shall be offset by income earned on in vestments unless the income is assigned by the donor. For the purpose of calculating the interest expense on debt incurred for capital costs to be included as financial re quirements after the sale and revaluation of a hospital, the debt may not exceed the revalued price of the hospital, as provided in sub. (4).

SB599,9,21 (c) Direct and indirect costs of medical education, allied education and research programs approved by the commission, to the extent that the costs are reasonable and necessary to maintain the quality of these programs. Costs under this para graph shall be reduced by tuition, scholarships, endowments, gifts, grants and simi lar sources of revenue.

SB599,9,24 (d) Costs of services, facilities and supplies that organizations related to the hospital by common ownership or control furnish to the hospital. These costs shall be calculated as the charge of the furnishing organization, but may not exceed a rea sonable amount in relation to the price of comparable services, facilities or supplies that could be purchased elsewhere.

SB599,10,5 (e) Unrecovered costs from private parties who fail to pay the full charge for care provided, unless the hospital fails to maintain sound credit and collection poli cies to minimize these costs.

SB599,10,6 (f) Fees assessed by the commission or other regulatory agencies.

SB599,10,14 (g) Operating fund working capital requirements. In this paragraph, "working capital requirements" means capital in use to operate the hospital at a level sufficient to avoid unnecessary borrowing, including cash, accounts receivable, inventory and prepaid expenses less accounts payable and accrued interest. Working capital re quirements shall be calculated independently of available funds, as defined in par. (i) 1. Working capital requirements shall be calculated based on the net change in the estimated year-end balance of the hospital's year under review, compared to the year-end balance of the hospital's prior fiscal year, for the following accounts:

SB599,10,15 1. Cash.

SB599,10,16 2. Accounts receivable.

SB599,10,17 3. Inventories.

SB599,10,18 4. Prepaid expenses.

SB599,10,19 5. Trade accounts payable.

SB599,10,20 6. Accrued interest payable.

SB599,11,2 (h) An amount necessary to establish and maintain a contingency fund in cash and investments equal to 2% of the budgeted gross revenue for the hospital's year under review. The hospital shall use cash and investments to establish and maintain its contingency fund and shall use the fund to meet unexpected expenses. The com mission may review any expenditure of contingency funds in a prior year that requires restoration in the hospital's year under review for reasonableness, consis tent with the nature of the unexpected expense.

SB599,11,6 (i) Capital requirements, calculated as the greater of historical, straight-line depreciation of plant and equipment or the cost of proposed capital purchases as off set by available funds, plus debt retirement expenses, prospective accumulation and capitalized interest. In this paragraph:

SB599,11,20 1. "Available funds" includes cash and investments that are not assigned by the donor and are available to meet capital needs. "Available funds" does not include op erating fund working capital requirements, prospective accumulations that are au thorized by the commission, donor-restricted or creditor-restricted funds, grants, commitments for capital requirements, debt retirement expenses or the amounts disallowed under s. 196.997 (1) (b). The commission may authorize prospective accu mulations if a capital project has lending requirements that necessitate such an ac cumulation or can lower its interest costs by borrowing, or if financial needs of a hos pital occur because of balloon payments. The commission may also authorize prospective accumulations to finance a capital project, if the cost of the capital project equals or exceeds 25% of the hospital's gross patient revenue for the current fiscal year, the hospital has submitted a 3-year capital expenditure plan to the commission and the department indicates that the capital project is consistent with the projected needs of the community.

SB599,11,22 2. "Capital purchases" includes minor remodeling and the purchase of equip ment, land, land improvements and leasehold improvements.

SB599,11,24 3. "Depreciation" means the rational allocation of the historical cost of capital ized assets throughout their useful lives.

SB599,12,2 4. "Prospective accumulation" does not include funds that exceed the cost of the capital project for which the funds are accumulated.

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.