Public Notices
Department of Health Services
Changes to Physician Reimbursement Rates
The State of Wisconsin reimburses providers for services provided to Medical Assistance recipients under the authority of Title XIX of the Social Security Act and ss.
49.43 to
49.47, Wisconsin Statutes. This program, administered by the State's Department of Health Services, is called Medical Assistance (MA) or Medicaid. In addition, Wisconsin has expanded this program to create the BadgerCare and BadgerCare Plus programs under the authority of Title XIX and Title XXI of the Social Security Act and ss.
49.471,
49.665, and
49.67 of the Wisconsin Statutes. Federal statutes and regulations require that a state plan be developed that provides the methods and standards for reimbursement of covered services. A plan that describes the reimbursement system for the services (methods and standards for reimbursement) is now in effect.
The Wisconsin Department of Health Services is proposing to implement two healthcare efficiency projects related to physician reimbursement. These projects will not require that the Medicaid state plan be amended, but they will affect provider reimbursement rates. Changes to provider reimbursement rates will be reflected on the maximum allowable fee schedules, available online through the ForwardHealth Portal at:
The first project (Payment Reform 14) would lower the rate paid to physicians and other professional providers for services typically provided in an office setting when those services are instead provided in a hospital or ambulatory surgery center. The list of affected services includes around 1,000 specific procedure codes. The adjusted reimbursement rate for these services when provided in a hospital or ambulatory surgery center would be set at 80% of the reimbursement rate when provided in an office setting.
The second project (Payment Reform 15) would lower reimbursement to physicians and other professional providers for consultation services to better match reimbursement for primary care services. The list of affected services includes 10 specific procedure codes.
Proposed Change
The proposed changes are to adjust reimbursement to physicians and other professional providers when certain services are provided in a hospital or ambulatory surgery center (Payment Reform 14) and to lower reimbursement to physicians and other professional providers for consultation services (Payment Reform 15). Payment Reform 14 is projected to result in savings of $3.75 million all funds (AF), composed of $1.5 million general purpose revenue (GPR), and $2.25 million federal match (FED). Payment Reform 15 is projected to result in savings of $4 million AF, composed of $1.6 million GPR and $2.4 million FED. The effective date of the proposal will be March 1, 2012.
Copies of the Proposed Change:
A copy of the proposed change may be obtained free of charge by calling or writing as follows:
Regular Mail
David Stepien
Bureau of Benefits Management
Division of Health Care Access and Accountability
P.O. Box 309
Madison, WI 53701-0309
Phone
David Stepien
(608) 267-9314
FAX
(608) 266-1096
Attention: David Stepien
A copy of the proposed change is available for review at the main office of any county department of social services or human services.
Written Comments:
Written comments are welcome. Written comments on the proposed changes may be sent by FAX, e-mail, or regular mail to the Department. The FAX number is (608) 266-1096.
The e-mail address is
david.stepien@wisconsin.gov. Regular mail can be sent to the above address. All written comments will be reviewed and considered.
The written comments will be available for public review between the hours of 7:45 a.m. and 4:30 p.m. daily in Room 350 of the State Office Building, 1 West Wilson Street, Madison, Wisconsin. Revisions may be made in the proposed changed methodology based on comments received.
