(b) Fee calculation.
Fees shall be determined in advance for each calendar year, except that divisions may determine fees in advance for each fiscal year. For purchased services, the contract rate and billable units to the purchaser should be identical to the fee and billable units to the responsible party or parties, wherever possible. Fees shall be determined by dividing either the number of patient days projected by the year in question, or, if the facility or service provides less than 24 hour care, the number of hours of billable client service projected for the year in question, into allowable anticipated facility or service-related expenditures for the year in question. For purchased services not easily converted to time units and where the contract or agreement specifies purchase units other than time, fees shall be set using the contract unit.
Expenditures mean ordinary and necessary budgeted non-capital expenses and depreciation on capital equipment. Cost standards that govern purchase of care and services under s. 46.036
, Stats., shall apply to expenditures for calculating the fee. Outlays associated with non-client-specific community service and with client services exempted under s. DHS 1.01 (4)
plus a pro-rata share of depreciation and associated administration or indirect costs are excluded. Where the facility establishes separate per-service fees, expenditures mean ordinary and necessary per-service expenses plus a pro-rata share of depreciation and indirect or administration costs.
(d) Calculating fees.
A division, a county department of social services, a county department established under s. 46.23
, Stats., or a private firm under contract to a division or county department responsible for the calculation of the facility or service fees may use forms provided by the department for the calculation of unit rates. Budgeted costs shall be segregated among cost centers based on groupings of programs which have significantly different costs. A single facility fee may be used if the facility does not provide services of a disparate nature with associated wide discrepancies in cost. Multi-service facilities providing services which are not covered by the uniform fee system may not include costs for those services in their calculations of fees.
DHS 1.04 Note
Note: An example of services of a disparate nature is services provided by psychiatrists in comparison with services provided by social workers.
DHS 1.04 Note
Note: A form that may be used to calculate unit rates is DMT 143, Uniform Fee Application, which is available along with instructions for filling it out from the Bureau of Fiscal Services, P.O. Box 7853, Madison, Wisconsin 53707-7853.
(e) Multiple therapist fees.
Where fees are computed according to professional disciplines (i.e. psychiatrist, psychologist, social worker, nurse, etc.), a fee for an hour of service provided by 2 or more professionals would be the sum of the hourly rates for each professional.
DHS 1.04 Note
Note: Example: The fee for an hour of service provided by a psychologist and social worker would be the sum of the hourly rate computed for each discipline.
(f) Group therapy fees.
Group therapy fees shall be computed by dividing the fee calculated according to par. (d)
by the projected number of non-family-related clients per group.
DHS 1.04 Note
DHS 1.04 Note
For group sessions conducted by one therapist with an average size of 7.
DHS 1.04 Note
Group fee = Therapist fee÷ 7
DHS 1.04 Note
For group sessions conducted by more than one therapist with an average group size of 10.
DHS 1.04 Note
Group fee = (Therapist 1 + Therapist 2 etc.) ÷ 10
Divisions, county departments of social services, and county departments established under s. 51.42
, Stats., shall approve rates for facilities they operate. This subdivision does not apply where another form of approval is set by law.
The administrative unit of a purchasing agency authorized to enter into contracts or agreements for purchased services may approve the fee or fees for purchased services. Any fee approval shall occur before execution of the contract or agreement and the approved fee or fees shall be part of the contract. If the purchaser chooses not to approve fees under this subdivision, fees shall be established in accordance with sub. (2) (a)
Where 2 or more agencies purchase the same service(s) from the same provider, the agency with the largest dollar contract shall have final approval of the facility fee or service fee(s) in question.
(h) Effective date of fee.
Fees in effect at any time shall remain in effect until new fees are determined and approved pursuant to these rules. No fees shall be modified without the prior consent of the fee-approving authority.
DHS 1.04(2)(a)(a) Contracted services.
Facilities providing services pursuant to contracts or agreements with a division, a county department of social services or a county department established under s. 46.23
, Stats., where the purchaser chooses not to approve fees under sub. (1) (g) 2.
, shall establish fees which are equal to the facility's usual and customary charge. Contracted facilities shall inform the purchasing authority of the usual and customary charges and of any changes in fees that take place during the contract period.
(b) Private practitioners.
For services provided by a private practitioner the fee shall be the usual and customary charge for such services when such charges are in accord with all laws or regulations governing such charges.
(c) Statewide rates.
Where the department has established a statewide rate for a service, that rate shall be the fee.
(d) County departments of social services.
In special circumstances with approval of the department, county departments of social services may use a fee of $12 per hour for services delivered by professional staff and $8 per hour for services provided by paraprofessionals instead of establishing fees under sub. (1)
. The department may adjust these rates to reflect changes in the Milwaukee consumer price index for all items, published by the U.S. department of labor. The base time for these adjustments shall be November 1978 at which time the index was 199.0.
(e) Other procedures.
With the approval of the department, fee approval authorities may use other fee-setting procedures for designated services or groups of services. The procedures shall follow these guidelines:
Those costs must be included in the department's allowable cost policy established under s. 46.036
The procedures may set more restrictive requirements for the costs to be considered; and
DHS 1.04 History
Cr. Register, August, 1978, No. 272
, eff. 9-1-78; am. (1) (intro.) and (a), renum. (1) (d) and (e) to be (1) (g) and (h), r. and recr. (1) (g), cr. (1) (d) to (f), Register, November, 1979, No. 287
, eff. 1-1-80; am. (1) (d) (intro.) and (2) (e), cr. (2) (f), Register, September, 1984, No. 345
, eff. 10-1-84; am. (1) (intro.), (g) 1. and 2., r. and recr. (1) (d) and (2) (a), Register, December, 1987, No. 384
, eff. 1-1-88.
DHS 1.05 Billing and collections responsibility and practice. DHS 1.05(1)(1)
Boards established under s. 51.42, 51.437 or 46.23, Stats. DHS 1.05(1)(a)(a)
With respect to each service not provided in state facilities, the responsibility for billing and collections pursuant to these rules shall be delegated to a board established under s. 51.42
, Stats., under authority established by s. 46.10 (16)
, Stats., subject to the conditions specified by the department. The board may further delegate responsibility for billing and collection to a service provider by written agreement specifying the conditions of such delegation.
Formal delegation is required for care received in county hospitals under s. 51.09
, Stats., on or after January 1, 1975. Until collections responsibility is delegated for these services, the department's bureau of fiscal services shall continue to manage these accounts. Delegation of collections for county hospitals may be granted to the program director of the appropriate 51.42 board upon submission of required form DMT 142 to the Secretary of the Department - Attention: Bureau of Fiscal Services. Where the board of trustees of the hospital is not the 51.42
board, application for delegated collections authority shall specify the role in the collections function and how any disposition of monies collected by the facility will be handled. When an application is received, a representative of the bureau of fiscal services shall visit the facility in question to determine the facility's capability to operate in accord with statutes and rules relative to the collections function.
DHS 1.05 Note
Note: Form DMT 142 may be obtained from:
Department of Health Services
Bureau of Fiscal Services
P.O. Box 7853
Madison, Wisconsin 53707-7853
For services provided in Milwaukee county-operated facilities, the provisions of s. 46.10 (12)
, Stats., take precedence over s. 46.10 (16)
, Stats. Therefore, Milwaukee county may continue to collect for these services without additional delegation authority. However, if Milwaukee county chooses not to operate under s. 46.10 (12)
, Stats., the provisions of s. 46.10 (16)
, Stats., will apply according to par. (d)
Collections for all other services purchased or provided by boards not mentioned in par. (b)
are delegated to the program director of the board.
Accounts collected by the department's bureau of fiscal services for boards established under s. 51.42
, Stats., shall be distributed according to s. 46.10 (8m)
Where services covered by these rules are delivered through a county department of social services, the county department of social services shall have billing and collection responsibility for those services unless it delegates such responsibility to a provider agency or agencies by written agreement specifying the conditions of such delegation.
Accounts collected by the department's bureau of fiscal services for county departments of social services shall be distributed according to s. 46.03 (18) (g)
When a child is placed in substitute care, as defined in s. DHS 1.07 (2) (i)
, pursuant to a court order under ch. 48
, Stats., the county agency under s. 46.215
, Stats., shall enter into an agreement with the county child support agency under s. 59.53 (5)
, Stats., to maximize federal financial participation in funding substitute care and to conform to federal statutes and regulations relating to parental support or payment for substitute care.
(3) Revocation of delegated authority.
All delegations under subs. (1)
are subject to revocation should the department find violations of these rules or of generally recognized good accounting practices.
(4) State bureau of fiscal services.
Except where responsibility for collections is delegated under sub. (1)
, the bureau of fiscal services of the department shall be responsible for the billing and collection function, unless otherwise specified by the secretary. The bureau of fiscal services shall also provide collection services for individual delinquent, or otherwise referred, client accounts.
(5) Further delegation.
Agencies with delegated collection responsibility may contract out the billing and collection functions as part of a purchase of service agreement. Such contracts shall specifically provide that all billing and collections functions be carried out according to these rules. However, no contract may be negotiated with a private collections firm without written permission from the bureau of fiscal services.
All billing and collection efforts shall strive toward what is fair and equitable treatment for both clients who receive service and taxpayers who bear unmet costs.
Billing and collection activity shall consider the rights, dignity, and physical and mental condition of the client and other responsible parties. Responsible parties with no ability to pay and without applicable insurance shall not be pursued for payment.
All billing and collection activity shall be pursued in a forthright and timely manner according to these rules:
Where applicable insurance exists, the insurance company shall be billed directly wherever possible by the unit with collection responsibility for the facility providing the service. Where a responsible party is covered by Medicare and private insurance, Medicare shall be billed for the full coverage it provides and the private insurance company shall be billed for any remaining amount. Medicaid, where applicable, is the payer of last resort. For services exempted by s. DHS 1.01 (4)
, third-party reimbursement shall be pursued where applicable, but direct billings to the client or other responsible parties shall not occur. Agencies shall follow the claims processing procedures of third-party payers to assure payment of claims.
Responsible private parties shall be billed for liability not covered by insurance, according to applicable provisions of s. DHS 1.03
(7) First billings to responsible parties who have an ability to pay or who have not provided full financial information.
Where it is anticipated third-parties will pay less than the full liability, the first billing to responsible parties shall be sent during the calendar month following the month in which services were provided, except where an agreement to delay billing exists. If a responsible party has not provided full financial information and the payment approval authority determines that it is unlikely that the responsible party is able to pay full uninsured liability, the payment approval authority may set an estimated payment amount which shall be adjusted retroactively after the responsible party has provided full financial information. A cover letter explaining the liability and arrangements for making payment shall accompany the first billing statement to the responsible person(s) billed.
(8) Content of billing statements to responsible parties.
The billing statement shall be designed to meet all the requirements of the uniform fee system in the laws, rules and this order and must allow for the following entries:
Any balance brought forward from the last statement.
Any services provided during the billing period with charges showing liability and adjustments for parental maximums (except billings to clients for full care) and adjustments for maximum monthly payment rate (except for inpatient accounts).
Total outstanding charges to date ((a) minus (b), plus (c)).
(9) Mailing billing statements.
When a statement or other correspondence is mailed to a responsible party, there shall be no information on the mailed item to indicate that the item is necessarily related to care or treatment for mental illness, developmental disability, alcoholism, drug abuse or any other condition treatable under the provisions of ch. 48
(10) Addressing billing statements.
Statements shall only be addressed to the following persons:
The client's spouse if the client is personally unable to pay the entire liability.
The guardian of the estate of a person adjudged incompetent under ch. 54, Stats.
A person appointed representative payee of social security or SSI benefits of a client or responsible party.
A person, agency or firm specifically designated through an informed release of information by the client or a person named in s. 51.30 (5) (a)
(11) Coordination where other liability exists.
Before billing responsible parties, agencies shall determine if a responsible party has outstanding payment responsibility from any previous social or mental hygiene service. Where such payment responsibility exists, the agency currently providing service shall inform the first agency of the party's present status and coordinate the application of payments from the responsible party according to s. DHS 1.03 (17)
and sub. (12)
. When charges are satisfied of the agency given priority, that agency shall notify the other agency to commence their billing.
Payments shall be applied to the oldest period of service for which a liability remains, except as provided in the following paragraphs of this subsection.
When a responsible party has liability for adult inpatient care and for some other type of service, payments shall not be applied to the adult inpatient liability until other liabilities have been satisfied according to these rules.
Payment from one responsible party shall have no effect on decreasing the liability of other responsible parties except as total liability is decreased.
When private insurers or government agencies make payments against claims or statements that specify dates of service, such payments shall be applied to liability for the period indicated.
For clients residing in facilities, payments from client's own income shall be applied to the liability incurred during the month the income is received except that retroactive benefits may be applied to liability incurred back to the date of entitlement. The priority of payments for clients residing in facilities is as follows:
DHS 1.05(13)(a)(a) Definition.
An account is considered delinquent when a determination has been made that ability to pay currently exists, that no payment has been made over a period of 90 days, and that 3 or more contacts have been made to secure a payment.
(b) Follow-up of accounts.
Each billing/collection unit shall have a procedure to review accounts periodically for follow-up. When no payment is made on the initial billing, a second billing showing accumulated monthly charges shall be sent during the next calendar month. A note shall be enclosed explaining the bill and the amount now due. No response after 30 days following the second billing suggests checking with the service staff to see if there are any known reasons why collection efforts should not be pursued. Options are to:
Modify the approach by writing individualized letters or making telephone or other contacts.
(bm) Determining courses of action for unclear cases.
The payment approval authority shall determine the course of action for unclear cases. Actions taken shall be documented in the client's collection file.
(c) Referral of accounts for collection.
Agencies shall refer accounts for collection when the accounts are considered delinquent as defined in par. (a)
and when the agency's own collection unit has completed required follow-up procedures.
The following channels shall be utilized, depending on their availability and potential for timely handling of the account:
District attorney or corporation counsel handling legal matters for the county department of social services, or 51.42, 51.437 or 46.23 board involved.
No referral may be made to a private collection agency or private law office without the written permission of the bureau of fiscal services.