49.45(2)(a)11.a.a. Establish criteria for certification of providers of medical assistance and, except as provided in
par. (b) 6m. and
s. 49.48, and subject to
par. (b) 7. and
8., certify providers who meet the criteria.
49.45(2)(a)12.a.a. Decertify a provider from or restrict a provider's participation in the medical assistance program, if after giving reasonable notice and opportunity for hearing the department finds that the provider has violated a federal statute or regulation or a state statute or administrative rule and the violation is, by statute, regulation, or rule, grounds for decertification or restriction. The department shall suspend the provider pending the hearing under this subdivision if the department includes in its decertification notice findings that the provider's continued participation in the medical assistance program pending hearing is likely to lead to the irretrievable loss of public funds and is unnecessary to provide adequate access to services to medical assistance recipients. As soon as practicable after the hearing, the department shall issue a written decision. No payment may be made under the medical assistance program with respect to any service or item furnished by the provider subsequent to decertification or during the period of suspension.
49.45(2)(a)12r.
12r. Notify the medical examining board, or any affiliated credentialing board attached to the medical examining board, of any decertification or suspension of a person holding a license granted by the board or the affiliated credentialing board if the grounds for the decertification or suspension include fraud or a quality of care issue.
49.45(2)(a)13.
13. Impose additional sanctions for noncompliance with the terms of provider agreements under
subd. 9. or certification criteria established under
subd. 11.
49.45(2)(a)14.
14. Assure due process in implementing
subds. 12. and
13. by providing written notice, a fair hearing and a written decision.
49.45(2)(a)15.
15. Routinely provide notification to persons eligible for medical assistance, or such persons' guardians, of the department's access to provider records.
49.45(2)(a)16.
16. Notify the joint committee on finance and appropriate standing committees in each house of the legislature prior to renewing, extending or amending the claims processing contract under the medical assistance program.
49.45(2)(a)18.
18. Conduct outreach for the early and periodic screening, diagnosis and treatment program as required under
42 CFR 441. This activity is limited to persons under 21 years of age who have been determined to be eligible for medical assistance.
49.45(2)(a)20.
20. Submit a report, by May 1, 1991, and annually thereafter, to the joint committee on finance on the participation rates of children in the early and periodic screening and diagnosis program.
49.45(2)(a)22.
22. After consulting with counties, independent living centers, consumer organizations and home health agencies, periodically identify those barriers to the provision of personal care services under
s. 49.46 (2) (b) 6. j. which lead to a failure to respond to the needs and preferences of individuals who are eligible for these services and act to remove the barriers to the extent possible.
49.45(2)(a)23.
23. Promulgate rules that define "supportive services", "personal services" and "nursing services" provided in a certified residential care apartment complex, as defined under
s. 50.01 (1d), for purposes of reimbursement under
ss. 46.27 (11) (c) 7. and
46.277 (5) (e).
49.45(2)(a)24.
24. In consultation with hospitals, health maintenance organizations, county departments of social services and of human services and other interested parties, develop and, not later than January 1, 1999, implement a process for expediting medical assistance eligibility determinations for persons in urgent medical situations. The department shall promulgate any rules necessary for the implementation of that process.
49.45(2)(a)24m.
24m. Promulgate rules that require that the written plan of care for persons receiving personal care services under medical assistance be reviewed by a registered nurse at least every 60 days. The rules shall provide that the written plan of care shall designate intervals for visits to the recipient's home by a registered nurse as part of the review of the plan of care. The designated intervals for visits shall be based on the individual recipient's needs, and each recipient shall be visited in his or her home by a registered nurse at least once in every 12-month period. The rules shall also provide that a visit to the recipient is also required if, in the course of the nurse's review of the plan of care, there is evidence that a change in the recipient's condition has occurred that may warrant a change in the plan of care.
49.45(2)(b)1.
1. Direct a county department under
s. 46.215,
46.22 or
46.23 to perform other functions, responsibilities and services, including any functions related to health maintenance organizations, limited service health organizations and preferred provider plans.
49.45(2)(b)2.
2. Contract with any organization whether or not organized for profit to administer, in full or in part, the benefits under the medical assistance program including prepaid health care. The department shall accept bids on contracts for administrative services and services evaluating the medical assistance program as provided in
ch. 16, but may accept the contract deemed most advantageous for claims processing services; or contract with any insurer authorized under the insurance code of this state to insure the program in full or in part and on behalf of the department. The department shall submit a report each December 31 to the governor, the joint committee on finance and the chief clerk of each house of the legislature, for distribution to the appropriate standing committees under
s. 13.172 (3), regarding the effectiveness of the management information system for monitoring and analyzing medical assistance expenditures.
49.45(2)(b)3.
3. Audit all claims filed by any contractor making the payment of benefits paid under
ss. 49.46 to
49.471 and make proper fiscal adjustments.
49.45(2)(b)4.
4. Audit claims filed by any provider of medical assistance, and as part of that audit, request of any such provider, and review, medical records of individuals who have received benefits under the medical assistance program.
49.45(2)(b)5.
5. Enter into contracts with providers who donate their services at no charge or who provide services for reduced payments.
49.45(2)(b)6m.
6m. Limit the number of providers of particular services that may be certified under
par. (a) 11. or the amount of resources, including employees and equipment, that a certified provider may use to provide particular services to medical assistance recipients, if the department finds that existing certified providers and resources provide services that are adequate in quality and amount to meet the need of medical assistance recipients for the particular services; and if the department finds that the potential for medical assistance fraud or abuse exists if additional providers are certified or additional resources are used by certified providers. The department shall promulgate rules to implement this subdivision.
49.45(2)(b)7.
7. Require, as a condition of certification under
par. (a) 11., all providers of a specific service that is among those enumerated under
s. 49.46 (2),
49.47 (6) (a), or
49.471 (11), as specified in this subdivision, to file with the department a surety bond issued by a surety company licensed to do business in this state. Providers subject to this subdivision provide those services specified under
s. 49.46 (2),
49.47 (6) (a), or
49.471 (11) for which providers have demonstrated significant potential to violate
s. 49.49 (1) (a),
(2) (a) or
(b),
(3),
(3m) (a),
(3p),
(4) (a), or
(4m) (a), to require recovery under
par. (a) 10., or to need additional sanctions under
par. (a) 13. The surety bond shall be payable to the department in an amount that the department determines is reasonable in view of amounts of former recoveries against providers of the specific service and the department's costs to pursue those recoveries. The department shall promulgate rules to implement this subdivision that specify all of the following:
49.45(2)(b)7.c.
c. Terms of the surety bond, including amounts, if any, without interest to be refunded to the provider upon withdrawal or decertification from the medical assistance program.
49.45(2)(b)8.
8. Require a person who takes over the operation, as defined in
sub. (21) (ag), of a provider, to first obtain certification under
par. (a) 11. for the operation of the provider, regardless of whether the person is currently certified. The department may withhold the certification required under this subdivision until any outstanding repayment under
sub. (21) is made. The department shall promulgate rules to implement this subdivision.
49.45(2)(b)9.
9. After providing reasonable notice and opportunity for a hearing, charge an assessment to a provider that repeatedly has been subject to recoveries under
par. (a) 10. a. because of the provider's failure to follow identical or similar billing procedures or to follow other identical or similar program requirements. The assessment shall be used to defray in part the costs of audits and investigations by the department under
sub. (3) (g) and may not exceed $1,000 or 200% of the amount of any such repeated recovery made, whichever is greater. The provider shall pay the assessment to the department within 10 days after receipt of notice of the assessment or the final decision after administrative hearing, whichever is later. The department may recover any part of an assessment not timely paid by offsetting the assessment against any medical assistance payment owed to the provider and may refer any unpaid assessments not collected in this manner to the attorney general, who may proceed with collection under this subdivision. Failure to timely pay in any manner an assessment charged under this subdivision, other than an assessment that is offset against any medical assistance payment owed to the provider, is grounds for decertification under
par. (a) 12. A provider's payment of an assessment does not relieve the provider of any other legal liability incurred in connection with the recovery for which the assessment is charged, but is not evidence of violation of a statute or rule. The department shall credit all assessments received under this subdivision to the appropriation account under
s. 20.435 (4) (iL). The department shall promulgate rules to implement this subdivision.
49.45(3)(a)(a) Reimbursement shall be made to each county department under
ss. 46.215,
46.22, and
46.23 for any administrative services performed in the Medical Assistance program on the basis of
s. 49.78 (8). For purposes of reimbursement under this paragraph, assessments completed under
s. 46.27 (6) (a) are administrative services performed in the Medical Assistance program.
49.45(3)(ag)
(ag) Reimbursement shall be made to each entity contracted with under
s. 46.283 (2) for functional screenings performed by the entity.
49.45(3)(b)1.1. The contractor, if any, administering benefits or providing prepaid health care under
s. 49.46,
49.465,
49.468,
49.47, or
49.471 shall be entitled to payment from the department for benefits so paid or prepaid health care so provided or made available when a certification of eligibility is properly on file with the contractor in addition to the payment of administrative expense incurred pursuant to the contract and as provided in
sub. (2) (a) 4., but the contractor shall not be reimbursed for benefits erroneously paid where no certification is on file.
49.45(3)(b)2.
2. The contractor, if any, insuring benefits under
s. 49.46,
49.465,
49.468,
49.47, or
49.471 shall be entitled to receive a premium, in an amount and on terms agreed, for such benefits for the persons eligible to receive them and for its services as insurer.
49.45(3)(c)
(c) Payment for services provided under this section shall be made directly to the hospital, skilled and intermediate nursing homes, prepaid health care group, other organization or individual providing such services or to an organization which provides such services or arranges for their availability on a prepayment basis.
49.45(3)(d)
(d) No payment may be made for inpatient hospital services, skilled nursing home services, intermediate care facility services, tuberculosis institution services or inpatient mental institution services, unless the facility providing such services has in operation a utilization review program and meets federal regulations governing such utilization review program.
49.45(3)(dm)
(dm) After distribution of computer software has been made under
1993 Wisconsin Act 16, section 9126 (13h), no payment may be made for home health care services provided to persons who are enrolled in the federal medicare program and are recipients of medical assistance under
s. 49.46,
49.47, or
49.471 unless the provider of the services has in use the computer software to maximize payments under the federal medicare program under
42 USC 1395.
49.45(3)(e)1.1. The department may develop, implement and periodically update methods for reimbursing or paying hospitals for allowable services or commodities provided a recipient. The methods may include standards and criteria for limiting any given hospital's total reimbursement or payment to that which would be provided to an economically and efficiently operated facility.
49.45(3)(e)2.
2. A hospital whose reimbursement or payment is determined on the basis of the methods developed and implemented under
subd. 1. shall annually prepare a report of cost and other data in the manner prescribed by the department.
49.45(3)(e)3.
3. The department may adopt a prospective payment system under
subd. 1. which may include consideration of an average rate per diem, diagnosis-related groups or a hospital-specific prospective rate per discharge.
49.45(3)(e)4.
4. If the department maintains a retrospective reimbursement system under
subd. 1. for specific provided services or commodities, total reimbursement for allowable services, care or commodities provided recipients during the hospital's fiscal year may not exceed the lower of the hospital's charges for the services or the actual and reasonable allowable costs to the hospital of providing the services, plus any disproportionate share funding that the hospital is qualified to receive under
42 USC 1396r-4.
49.45(3)(e)7.
7. The daily reimbursement or payment rate to a hospital for services provided to medical assistance recipients awaiting admission to a skilled nursing home, intermediate care facility, community-based residential facility, group home, foster home, treatment foster home or other custodial living arrangement may not exceed the maximum reimbursement or payment rate based on the average adjusted state skilled nursing facility rate, created under
sub. (6m). This limited reimbursement or payment rate to a hospital commences on the date the department, through its own data or information provided by hospitals, determines that continued hospitalization is no longer medically necessary or appropriate during a period where the recipient awaits placement in an alternate custodial living arrangement. The department may contract with a peer review organization, established under
42 USC 1320c to
1320c-10, to determine that continued hospitalization of a recipient is no longer necessary and that admission to an alternate custodial living arrangement is more appropriate for the continued care of the recipient. In addition, the department may contract with a peer review organization to determine the medical necessity or appropriateness of physician services or other services provided during the period when a hospital patient awaits placement in an alternate custodial living arrangement.
Effective date note
NOTE: Subd. 7. is amended by
2009 Wis. Act 28 eff. the date stated in the notice provided by the secretary of children and families and published in the Wisconsin Administrative Register under s. 48.62 (9) to read:
Effective date text
7. The daily reimbursement or payment rate to a hospital for services provided to medical assistance recipients awaiting admission to a skilled nursing home, intermediate care facility, community-based residential facility, group home, foster home, or other custodial living arrangement may not exceed the maximum reimbursement or payment rate based on the average adjusted state skilled nursing facility rate, created under sub. (6m). This limited reimbursement or payment rate to a hospital commences on the date the department, through its own data or information provided by hospitals, determines that continued hospitalization is no longer medically necessary or appropriate during a period when the recipient awaits placement in an alternate custodial living arrangement. The department may contract with a peer review organization, established under 42 USC 1320c to 1320c-10, to determine that continued hospitalization of a recipient is no longer necessary and that admission to an alternate custodial living arrangement is more appropriate for the continued care of the recipient. In addition, the department may contract with a peer review organization to determine the medical necessity or appropriateness of physician services or other services provided during the period when a hospital patient awaits placement in an alternate custodial living arrangement.
49.45(3)(e)7m.
7m. Notwithstanding
subd. 7., the daily reimbursement or payment rate for services at a hospital established under
s. 45.50 (10) provided to medical assistance recipients whose continued hospitalization is no longer medically necessary or appropriate during a period where the recipient awaits placement in an alternate custodial living arrangement shall be the skilled nursing facility rate paid to a Wisconsin veterans home operated by the department of veterans affairs under
s. 45.50.
49.45(3)(e)9.
9. Hospital research costs that the department finds to be indirectly related to patient care are not allowable costs in establishing a hospital's reimbursement or payment rate under
subd. 1.
49.45(3)(e)10.
10. Hospital procedures on an inpatient basis that could be performed on an outpatient basis shall be reimbursed or paid at the outpatient rate. The department shall determine which procedures this subdivision covers.
49.45(3)(e)10m.
10m. All facilities listed in a certificate of approval issued to the University of Wisconsin Hospitals and Clinics Authority under
s. 50.35 are a hospital for purposes of reimbursement under this section.
49.45(3)(e)10r.
10r. All facilities listed in a certificate of approval issued to a free-standing pediatric teaching hospital under
s. 50.35 are a hospital for purposes of reimbursement under this section. Notwithstanding this subdivision, the department shall use physician clinic reimbursement rates to reimburse the facilities under this section for types of services for which, before July 1, 2009, the department reimbursed the facilities using physician clinic reimbursement rates, as determined by the department.
49.45(3)(e)11.
11. The department shall use a portion of the moneys collected under
s. 50.38 (2) (a) to pay for services provided by eligible hospitals, as defined in
s. 50.38 (1), other than critical access hospitals, under the Medical Assistance Program under this subchapter, including services reimbursed on a fee-for-service basis and services provided under a managed care system. For state fiscal year 2008-09, total payments required under this subdivision, including both the federal and state share of Medical Assistance, shall equal the amount collected under
s. 50.38 (2) (a) for fiscal year 2008-09 divided by 57.75 percent. For each state fiscal year after state fiscal year 2008-09, total payments required under this subdivision, including both the federal and state share of Medical Assistance, shall equal the amount collected under
s. 50.38 (2) (a) for the fiscal year divided by 61.68 percent.
49.45(3)(e)12.
12. The department shall use a portion of the moneys collected under
s. 50.38 (2) (b) to pay for services provided by critical access hospitals under the Medical Assistance Program under this subchapter, including services reimbursed on a fee-for-service basis and services provided under a managed care system. For each state fiscal year, total payments required under this subdivision, including both the federal and state share of Medical Assistance, shall equal the amount collected under
s. 50.38 (2) (b) for the fiscal year divided by 61.68 percent.
49.45(3)(f)1.1. Providers of services under this section shall maintain records as required by the department for verification of provider claims for reimbursement. The department may audit such records to verify actual provision of services and the appropriateness and accuracy of claims.
49.45(3)(f)2.
2. The department may deny any provider claim for reimbursement which cannot be verified under
subd. 1. or may recover the value of any payment made to a provider which cannot be so verified. The measure of recovery will be the full value of any claim if it is determined upon audit that actual provision of the service cannot be verified from the provider's records or that the service provided was not included in
s. 49.46 (2) or
49.471 (11). In cases of mathematical inaccuracies in computations or statements of claims, the measure of recovery will be limited to the amount of the error.
49.45(3)(f)2m.
2m. The department shall adjust reimbursement claims for hospital services that are provided during a period when the recipient awaits placement in an alternate custodial living arrangement under
par. (e) 7. and that fail to meet criteria the department may establish concerning medical necessity or appropriateness for hospital care. In addition, the department shall deny any provider claim for services that fail to meet criteria the department may establish concerning medical necessity or appropriateness.
49.45(3)(f)3.
3. Contractors under
sub. (2) (b) shall maintain records as required by the department for audit purposes. Contractors shall provide the department access to the records upon request of the department, and the department may audit the records.
49.45(3)(fm)
(fm) The department shall seek, on behalf of dentists who are providers, federal reimbursement for the cost of any equipment that the department requires dentists to use to verify medical assistance eligibility electronically. If the department is successful in obtaining federal reimbursement of that expense, the department shall reimburse dentists who are providers for the portion of the cost of the equipment that is reimbursed by the federal government.
49.45(3)(g)1.1. The secretary may authorize personnel to audit or investigate and report to the department on any matter involving violations or complaints alleging violations of statutes, regulations, or rules applicable to the medical assistance program and to perform such investigations or audits as are required to verify the actual provision of services or items available under the medical assistance program and the appropriateness and accuracy of claims for reimbursement submitted by providers participating in the program. Department employees authorized by the secretary under this paragraph shall be issued, and shall possess at all times while they are performing their investigatory or audit functions under this section, identification, signed by the secretary, that specifically designates the bearer as possessing the authorization to conduct medical assistance investigations or audits. Under the request of a designated person and upon presentation of the person's authorization, providers and medical assistance recipients shall accord the person access to any provider personnel, records, books, or documents or other information needed. Under the written request of a designated person and upon presentation of the person's authorization, providers and recipients shall accord the person access to any needed patient health care records of a recipient. Authorized employees may hold hearings, administer oaths, take testimony, and perform all other duties necessary to bring the matter before the department for final adjudication and determination.
49.45(3)(g)2.
2. The department shall promulgate rules to implement this paragraph.
49.45(3)(h)1m.1m. The failure or refusal of a provider to accord department auditors or investigators access as required under
par. (g) to any provider personnel, records, books, patient health care records of medical assistance recipients, or documents or other information requested constitutes grounds for decertification or suspension of the provider from participation in the medical assistance program. No payment may be made for services rendered by the provider following decertification, during the period of suspension, or during any period of provider failure or refusal to accord access as required under
par. (g).
49.45(3)(h)1n.
1n. The department shall promulgate rules to implement this paragraph.
49.45(3)(j)
(j) Reimbursement for administrative contract costs under this section is limited to the funds available under
s. 20.435 (4) (bm).
49.45(3)(k)
(k) If a physician performs a surgical procedure that is within the scope of practice of a podiatrist, as defined in
s. 448.60 (3), the allowable charge for the procedure may not exceed the charge the department determines is reasonable.
49.45(3)(L)2.
2. The department may not pay a provider for a designated health service that is authorized under this section or
s. 49.46,
49.47, or
49.471, that is provided as the result of a referral made to the provider by a physician and that, under
42 USC 1396b (s), if made on behalf of a beneficiary of medicare under the requirements of
42 USC 1395nn, as amended to August 10, 1993, would result in the denial of payment for the service under
42 USC 1395nn.
49.45(3)(L)3.
3. A provider shall submit to the department information concerning the ownership arrangements of the provider or the entity of which the provider is a part that corresponds to the information required of providers under
42 USC 1395nn (f), as amended to August 10, 1993.
49.45(3)(L)4.
4. Any person who fails to comply with
subd. 3. may be required to forfeit not more than $10,000. Each day of continued failure to comply constitutes a separate offense.
49.45(3)(m)1.1. To be certified under
sub. (2) (a) 11. to provide transportation by specialized medical vehicle, a person must have at least one human service vehicle, as defined in
s. 340.01 (23g), that satisfies the requirements imposed under
s. 110.05 for a vehicle that is used to transport a person in a wheelchair. If a certified provider uses 2 or more vehicles to provide transportation by specialized medical vehicle, at least 2 of the vehicles must be human service vehicles that satisfy the requirements imposed under
s. 110.05 for a vehicle that is used to transport a person in a wheelchair, and any 3rd or additional vehicle must be a human service vehicle to which the equipment required under
s. 110.05 for transporting a person in a wheelchair may be added. The department shall pay for transportation by specialized medical vehicle under
s. 49.46 (2) (b) 3. or
49.471 (11) (m) that is provided in a human service vehicle that is not equipped to transport a person in a wheelchair if the person being transported does not use a wheelchair. The reimbursement rate for transportation by specialized medical vehicle provided in a vehicle that is not equipped to accommodate a wheelchair shall be the same as for transportation by specialized medical vehicle provided in a vehicle that is equipped to accommodate a wheelchair.
49.45(3)(m)2.
2. A person who is certified to provide transportation by specialized medical vehicle under
sub. (2) (a) 11. shall ensure that every person who drives or serves as an attendant to passengers on a specialized medical vehicle, before driving or serving as an attendant, has current proficiency in the use of an automated external defibrillator, as defined in
s. 256.15 (1) (cr), achieved through instruction provided by an individual, organization, or institution of higher education that is approved under
s. 46.03 (38) to provide such instruction.
49.45(4)
(4) Information restricted. The use or disclosure of any information concerning applicants and recipients of medical assistance not connected with the administration of this section is prohibited.
49.45(5)(a)(a) Any person whose application for medical assistance is denied or is not acted upon promptly or who believes that the payments made in the person's behalf have not been properly determined or that his or her eligibility has not been properly determined may file an appeal with the department pursuant to
par. (b). Review is unavailable if the decision or failure to act arose more than 45 days before submission of the petition for a hearing.
49.45(5)(b)1.1. Upon receipt of a timely petition under
par. (a) the department shall give the applicant or recipient reasonable notice and opportunity for a fair hearing. The department may make such additional investigation as it considers necessary. Notice of the hearing shall be given to the applicant or recipient and, if a county department under
s. 46.215,
46.22, or
46.23 is responsible for making the medical assistance determination, to the county clerk of the county. The county may be represented at such hearing. The department shall render its decision as soon as possible after the hearing and shall send a certified copy of its decision to the applicant or recipient, to the county clerk, and to any county officer charged with administration of the Medical Assistance program. The decision of the department shall have the same effect as an order of a county officer charged with the administration of the Medical Assistance program. The decision shall be final, but may be revoked or modified as altered conditions may require. The department shall deny a petition for a hearing or shall refuse to grant relief if:
