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Ins 17.28(6)(p)1. 1. 7.0% of the amount the entity pays as premium for its primary health care liability insurance, if it has occurrence coverage.
Ins 17.28(6)(p)2. 2. 10.0% of the amount the entity pays as premium for its primary health care liability insurance, if it has claims-made coverage.
Ins 17.28(6)(q) (q) For an organization or enterprise not specified as a partnership or corporation that is organized and operated in this state for the primary purpose of providing the medical services of physicians or nurse anesthetists, all of the following fees:
Ins 17.28(6)(q)1.a.a. If the total number of employed physicians and nurse anesthetists is from 1 to 10   $ 51
Ins 17.28(6)(q)1.b. b. If the total number of employed physicians and nurse anesthetists is from 11 to 100   $ 503
Ins 17.28(6)(q)1.c. c. If the total number of employed physicians or nurse anesthetists exceeds 100   $ 1,252
Ins 17.28(6)(q)2. 2. The following for each full-time equivalent allied health care professional employed by the organization or enterprise not specified as a partnership, corporation, or an operational cooperative health care plan as of the most recent completed survey submitted:
Employed Health Care Professionals   Fund Fee
Nurse Practitioners   $ 364
Advanced Nurse Practitioners   510
Nurse Midwives   3,205
Advanced Nurse Midwives   3,351
Advanced Practice Nurse Prescribers   510
Chiropractors     583
Dentists     291
Oral Surgeons   2,186
Podiatrists-Surgical   6,192
Optometrists     291
Physician Assistants   291
Ins 17.28(6d) (6d)Primary purpose presumption. For purposes of s. 655.002 (1) (e), Stats., and this section, it is presumed:
Ins 17.28(6d)(a) (a) A corporation organized and operated in this state of which 50% or more of its shareholders are physicians or nurse anesthetists is organized and operated in this state for the primary purpose of providing the medical services of physicians or nurse anesthetists.
Ins 17.28(6d)(b) (b) Conclusively that a corporation organized and operated in this state of which less than 50% of its shareholders are physicians or nurse anesthetists is not organized and operated in this state for the primary purpose of providing the medical services of physicians or nurse anesthetists.
Ins 17.28 Note Note: A person who disputes the application of this presumption to the person may be entitled to a hearing on the issue in accordance with s. 227.42, Stats.
Ins 17.28(6e) (6e)Medical college residents' fees.
Ins 17.28(6e)(a)(a) The fund shall calculate the total amount of fees for all medical college of Wisconsin affiliated hospitals, inc., and UW hospital and clinics, residents on a full-time-equivalent basis, taking into consideration the proportion of time spent by the residents in practice which is not covered by the fund, including practice in federal, state, county and municipal facilities, as determined and documented by the medical college of Wisconsin affiliated hospitals, inc., and UW hospital and clinics, respectively.
Ins 17.28(6e)(b) (b) Notwithstanding sub. (4) (h), the fund's initial bill for each fiscal year shall be the amount the medical college of Wisconsin affiliated hospitals, inc., estimates will be due for the next fiscal year for all its residents. At the end of the fiscal year, the fund shall adjust the fee to reflect the residents' actual exposure during the fiscal year, as determined by the medical college of Wisconsin affiliated hospitals, inc., and shall bill the medical college of Wisconsin affiliated hospitals, inc., for the balance due, if any, plus accrued interest, as calculated under sub. (4) (j) 2., from the beginning of the fiscal year. The fund shall refund the amount of an overpayment, if any.
Ins 17.28(6m) (6m)Reporting.
Ins 17.28(6m)(a) (a) The fund may require any provider to report, at the times and in the manner prescribed by the fund, any information necessary for the determination of a fee specified under sub. (6).
Ins 17.28(6m)(b) (b) For purposes of sub. (6) (k) to (m), a partnership or corporation shall report the number of partners, shareholders and employed physicians and nurse anesthetists on July 1 of the previous fiscal year.
Ins 17.28(6s) (6s)Surcharge.
Ins 17.28(6s)(a) (a) This subsection implements s. 655.27 (3) (bg) 1., Stats., requiring the establishment of an automatic increase in a provider's fund fee based on loss and expense experience.
Ins 17.28(6s)(b) (b) In this subsection:
Ins 17.28(6s)(b)1. 1. “Aggregate indemnity" has the meaning given under s. Ins 17.285 (2) (a).
Ins 17.28(6s)(b)2. 2. “Closed claim" has the meaning given under s. Ins 17.285 (2) (b).
Ins 17.28(6s)(b)3. 3. “Provider" has the meaning given under s. Ins 17.285 (2) (d).
Ins 17.28(6s)(b)4. 4. “Review period" has the meaning given under s. Ins 17.285 (2) (e).
Ins 17.28(6s)(c) (c) The following tables shall be used in making the determinations required under s. Ins 17.285 as to the percentage increase in a provider's fund fee:
Ins 17.28(6s)(c)1. 1. For a class 1 physician or a nurse anesthetist: - See PDF for table PDF
Ins 17.28(6s)(c)2. 2. For a class 2 physician: - See PDF for table PDF
Ins 17.28(6s)(c)3. 3. For a class 3 physician: - See PDF for table PDF
Ins 17.28(6s)(c)4. 4. For a class 4 physician: - See PDF for table PDF
Ins 17.28 Note Note: For a complete history of s. Ins 17.28 from June 1980 through August 31, 2000, see the History note following s. Ins 17.28 published in Register August 2000 No. 536.
Ins 17.28 History History: Cr. Register, June, 1980, No. 294, emerg. r. and recr. (6) and am. (6a), eff. 7-1-00; r. and recr. (6) and am. (6a), Register, August, 2000, No. 536, eff. 9-1-00; emerg. r. and recr. (6) and am. (6a), eff. 7-1-01; CR 01-035: r. and recr. (6) and am. (6a), Register September 2001 No. 549, eff. 10-1-01; emerg. r. and recr. (6), r. (6a), eff. 7-1-02; CR 02-035: r. and recr. (6), r. (6a), Register September 2002 No. 561, eff. 10-1-02; CR 03-039: r. and recr. (6) Register October 2003 No. 574, eff. 11-1-03; CR 04-032: r. and recr. (6) Register January 2005 No. 589, eff. 2-1-05; emerg. r. and recr. (6), eff. 7-1-05; CR 05-028: r. and recr. (6) Register October 2005 No. 598, eff. 11-1-05; CR 06-002: am. (3) (c) 1. and 2. and r. and recr. (6) Register June 2006 No. 606, eff. 7-1-06; CR 07-002: am. (6), Register June 2007 No. 618, eff. 7-1-07; CR 07-002: am. (6e), Register June 2007 No. 618, eff. 7-1-07; CR 08-006: am. (6) (intro.), (k) 2., (L) 2., (m) 2., (n) 3. and (q) 2. Register June 2008 No. 630, eff. 7-1-08; CR 09-004: am. (3) (c), r. and recr. (6) Register June 2009 No. 642, eff. 7-1-09; correction in (6) (o) made under s. 13.92 (4) (b) 7., Stats., Register June 2009 No. 642; CR 09-055: cr. (3h) Register March 2010 No. 651, eff. 4-1-10; EmR1020: emerg. r. and recr. eff. 6-15-10; CR 10-065: r. and recr. Register November 2010 No. 659, eff. 12-1-10; correction in (6) (o) made under s. 13.92 (4) (b) 7., Stats., Register November 2010 No. 659; EmR1108: emerg. am. (3) (c), r. and recr. (6) eff. 6-10-11; CR 11-015: am. (3) (c), r. and recr. (6) and Register August 2011 No. 668, eff. 9-1-11; EmR1306: emerg. am. (3) (c) 1. to 3., r. and recr. (6), eff. 6-3-13; CR 13-044: am. (3) (c) 1. to 3., r. and recr. (6) Register June 2014 No. 702, eff. 7-1-14; CR 19-119 am. (3) (c) 1. to 3., (4) (f) Register July 2020 No. 775, eff. 8-1-20.
Ins 17.285 Ins 17.285Peer review council.
Ins 17.285(1)(1)Purpose. This section implements ss. 619.04 (5) (b) and (5m) (b), 655.27 (3) (a) 2m. and (bg) 2. and 655.275, Stats.
Ins 17.285(2) (2)Definitions. In this section:
Ins 17.285(2)(a) (a) “Aggregate indemnity" means the total amount attributable to an individual provider that is paid or owing to or on behalf of claimants for all closed claims arising out of one incident or course of conduct, including amounts held by the fund under s. 655.015, Stats. “Aggregate indemnity" does not include any expenses paid in the defense of the claim.
Ins 17.285(2)(b) (b) “Closed claim" means a medical malpractice claim against a provider, or a claim against an employee of a health care provider for which the provider is vicariously liable, for which there has been either of the following:
Ins 17.285(2)(b)1. 1. A final determination based on a settlement, award or judgment that indemnity will be paid to or on behalf of a claimant.
Ins 17.285(2)(b)2. 2. A payment to a claimant by the provider or another person on the provider's behalf.
Ins 17.285(2)(c) (c) “Council" means the peer review council appointed under s. 655.275, Stats.
Ins 17.285(2)(cg) (cg) “Health care provider" has the meaning given in s. 146.81 (1), Stats.
Ins 17.285(2)(cr) (cr) “Patient health care records" has the meaning given in s. 146.81 (4), Stats.
Ins 17.285(2)(d) (d) “Provider," when used without further qualification, means a health care provider subject to ch. 655, Stats., who is a natural person. “Provider" does not include a hospital or other facility or entity that provides health care services.
Ins 17.285(2)(e) (e) “Review period" means the 5-year period ending with the date of the first payment on the most recent closed claim reported under s. 655.26, Stats., for a specific provider.
Ins 17.285(2)(f) (f) “Surcharge" means the automatic increase in a provider's plan premium or fund fee established under s. Ins 17.25 (12m) or 17.28 (6s) or both.
Ins 17.285(2m) (2m)Time for reporting. In reporting claims paid under s. 655.26, Stats., each insurer or self-insurer shall report the required information by the 15th day of the month following the date on which there has been a final determination of the aggregate indemnity to be paid to or on behalf of any claimant.
Ins 17.285(2s) (2s)Information for provider. Upon receipt of a report under sub. (2m), the council shall mail to the provider who is the subject of the report all of the following:
Ins 17.285(2s)(a) (a) A copy of the report, with a statement that the provider may contact the insurer that filed the report if the provider believes it contains inaccurate information.
Ins 17.285(2s)(b) (b) A statement that the council may use its authority under s. 146.82 (2) (a) 5., Stats., to obtain any patient health care records necessary for use in making determinations under this section.
Ins 17.285(2s)(c) (c) A request that the provider sign and return to the council an authorization for release of information form, authorizing the provider's insurer to provide the council with relevant factual information about the closed claim for use in making determinations under this section. A copy of the form shall be enclosed with the mailing.
Ins 17.285(2s)(d) (d) If necessary, a request that the provider verify the council's closed claim record and furnish the council with information on any additional closed claims not known to the council that have been paid by or on behalf of the provider during the review period.
Ins 17.285(2s)(e) (e) Notice that if the provider does not comply with a request under par. (c) or (d) within 40 days after the date of the request, the provider is in violation of s. 601.42 (4), Stats., and may be subject to a forfeiture of up to $1,000 for each week of continued violation, as provided in s. 601.64 (3), Stats.
Ins 17.285(3) (3)Determination of need for review. Based on reports received under sub. (2m) and any additional closed claims reported in response to a request under sub. (2s) (d), the council, using the tables under ss. Ins 17.25 (12m) (c) and 17.28 (6s) (c), shall determine when a provider has, during a review period, accumulated enough closed claims and aggregate indemnity to consider the imposition of a surcharge.
Ins 17.285(4) (4)Records requests; notice to provider.
Ins 17.285(4)(a)(a) When the council makes a determination under sub. (3), it may request any of the following:
Ins 17.285(4)(a)1. 1. From any health care provider, patient health care records related to each closed claim subject to review as provided in s. 146.82 (2) (a) 5., Stats.
Ins 17.285(4)(a)2. 2. From the provider's insurer, relevant factual information about each closed claim subject to review. This subdivision applies only if the provider has complied with the request under sub. (2s) (c).
Ins 17.285(4)(b) (b) A request under par. (a) shall be in writing and shall specify a reasonable time for response. Each person receiving a request shall provide the council with the records and information requested, unless the person no longer maintains or has access to them. If a person is unable to comply with a request, the person shall notify the council in writing of the reason for the inability to comply.
Ins 17.285(4)(c) (c) The council shall notify a provider for whom a determination is made under sub. (3) that, after reviewing the patient health care records, consultants' opinions and other relevant information submitted by the provider and the provider's insurer, the council may recommend that a surcharge be imposed on the provider's plan premium, fund fee or both, and that the surcharge may be reduced or eliminated following a review as provided in this section. The notice shall include a description of the procedures specified in this section and a statement that the provider may submit in writing relevant information about any closed claim involved in the review and a description of mitigating circumstances that may reduce the future risk to the plan, the fund or both.
Ins 17.285(5) (5)Procedure for review.
Ins 17.285(5)(a) (a) The council or a single council member may conduct a preliminary review of the records and information relating to each of a provider's closed claims. If the council or council member is able to determine, without a consultant, that the provider met the appropriate standard of care with respect to any closed claim, the council shall not refer that closed claim to a consultant and shall not use that closed claim in determining whether to impose a surcharge on that provider.
Ins 17.285(5)(b) (b) Unless a determination under par. (a) reduces the number of closed claims and aggregate indemnity so that the provider is no longer subject to the imposition of a surcharge, the council shall refer all records and information relating to closed claims subject to review, including records and information in the custody of the plan and the fund, to one or more specialists as provided in s. 655.275 (5) (b), Stats.
Ins 17.285(5)(c) (c) Each specialist consulted under par. (b) shall provide the council with a written opinion as to whether the provider met the appropriate standard of care with respect to each closed claim reviewed.
Ins 17.285(5)(d) (d) At least 30 days before the meeting at which the council will decide whether or not to recommend that a surcharge should be imposed on a provider, the council shall notify the provider of the date of the meeting and furnish the provider with a copy of the consultant's opinions and a list of any other documents on which the recommendation will be based. The council shall make all documents available to the provider upon request for inspection and copying, as provided under s. 19.35, Stats.
Ins 17.285(5)(e) (e) In reviewing a closed claim, the council or a consultant may consider any relevant information except information from a juror who participated in a civil action for damages arising out of an incident under review. The council or a consultant may consult with any person except a juror, interview the provider, employees of the provider or other persons involved in an incident or request the provider to furnish additional information or records.
Ins 17.285(5)(f) (f) The council, after taking into consideration all available information, shall decide whether each closed claim reviewed should be counted in recommending whether to impose a surcharge on the provider.
Ins 17.285(7) (7)Report to board.
Ins 17.285(7)(a) (a) If the total number of closed claims which the council determines should be included and the aggregate indemnity attributable to those claims would be sufficient to require the imposition of a surcharge under s. Ins 17.25 (12m) (c), 17.28 (6s) (c) or both, the council shall prepare a written report for the board recommending the surcharge that should be imposed. The report shall include the factual basis for the determination on each incident involved in the review and a description of any mitigating circumstances.
Ins 17.285(7)(b) (b) If the council determines that one or more closed claims should not be counted and, as a result, the total number of closed claims remaining and the aggregate indemnity attributable to those claims is not sufficient to require the imposition of a surcharge, the council shall prepare a written report for the board recommending that no surcharge should be imposed. The report shall include a brief summary of the basis for the recommendation.
Ins 17.285(7)(c) (c) The council shall furnish the provider with a copy of its report and recommendation to the board and with notice of the right to a hearing as provided in sub. (9).
Ins 17.285(9) (9)Hearing.
Ins 17.285(9)(a) (a) A provider has the right to a hearing under ch. 227, Stats., and ch. Ins 5 on the council's recommendation, if the provider requests a hearing within 30 days after receiving the notice under sub. (7) (c).
Ins 17.285(9)(am) (am) The reports of the consultant and any other documents relied on by the council in making its recommendation to the board are admissible in evidence at a hearing under this section.
Ins 17.285(9)(b) (b) Notice of the hearing examiner's proposed decision shall inform the provider that he or she may submit to the board written objections and arguments regarding the proposed findings of fact, conclusions of law and decision within 20 days after the date of the notice.
Ins 17.285(10) (10)Final decision; judicial review. The board shall make the final decision on the imposition of a surcharge. The final decision is reviewable by the circuit court as provided under ch. 227, Stats.
Ins 17.285(11) (11)Surcharge; imposition; refund; duration.
Ins 17.285(11)(a)(a) A surcharge imposed on a provider's plan premium, fund fee or both after a final decision by the board takes effect on the next billing date and remains in effect during any period of judicial review.
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Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.