Chapter DHS 120

DHS 120.21   Guide to Wisconsin hospitals.

DHS 120.22   Utilization, charge and quality reports.

DHS 120.23   Consumer guide.

DHS 120.24   Hospital rate increase report.

DHS 120.25   Uncompensated health care services report.

DHS 120.26   Hospital quality indicators report.

Subchapter V — Data Dissemination

DHS 120.29   Public use files.

DHS 120.30   Patient data elements considered patient-identifiable.

DHS 120.31   Data dissemination.

Ch. DHS 120 Note Note: Chapter HSS 120 was renumbered ch. Ins 120, Register, February, 1995, No. 470, eff. 3-1-95. Corrections made under s. 13.93 (2m) (b) 6. and 7., Stats., Register, June, 1997, No. 498. Chapter Ins 120 was renumbered Chapter HFS 120 under s. 13.93 (2m) (b) 1., Stats., and corrections made under s. 13.93 (2m) (b) 6. and 7., Stats., Register, January, 1998, No. 505. Chapter HFS 120 was repealed and recreated, Register, December, 2000, No. 540, eff. 1-1-01. Chapter HFS 120 was renumbered to chapter DHS 120 under s. 13.92 (4) (b) 1., Stats., and corrections made under s. 13.92 (4) (b) 7, Stats., Register January 2009 No. 637.

subch. I of ch. DHS 120 Subchapter I — General Provisions

DHS 120.01 DHS 120.01 Authority and purpose. This chapter is promulgated under the authority of s. 153.75, Stats., to implement ch. 153, Stats. Its purpose is to provide to health care providers, insurers, consumers, governmental agencies and others information concerning health care providers and uncompensated health care services, and provide information to assist in peer review for the purpose of quality assurance.

DHS 120.01 History History: Cr. Register, December, 2000, No. 540, eff. 1-1-01.

DHS 120.02 DHS 120.02 Applicability. This chapter applies to the department, the board on health care information, the independent review board, qualified vendors, health care plans, health care providers licensed in this state and persons requesting data from the department.

DHS 120.02 History History: Cr. Register, December, 2000, No. 540, eff. 1-1-01; CR 03-033: am. Register December 2003 No. 576, eff. 1-1-04.

DHS 120.03 DHS 120.03 Definitions. Unless otherwise indicated, in this chapter:

DHS 120.03(1) (1) “Affirmation statement” means a department document that when signed by a health care provider or an authorized representative of a health care provider submitting data to the department affirms, to the best of the signer’s knowledge, all of the following:

DHS 120.03(1)(a) (a) Any necessary corrections to data submitted to the department have been made.

DHS 120.03(1)(b) (b) The data submitted are complete and accurate.

DHS 120.03(2) (2) “Bad debts” means claims arising from rendering patient care services that the hospital, using a sound credit and collection policy, determines are uncollectible, but does not include charity care.

DHS 120.03(3) (3) “Board” means the board on health care information established under s. 15.195 (6), Stats.

DHS 120.03 Note Note: Section 15.195 (6), Stats., was repealed by 2005 Wis. Act 228.

DHS 120.03(4) (4) “Charity care” means health care a hospital provides to a patient who, after an investigation of the circumstances surrounding the patient’s ability to pay, including nonqualification for a public program, is determined by the hospital to be unable to pay all or a portion of the hospital’s normal billed charges. “Charity care” does not include any of the following:

DHS 120.03(4)(a) (a) Care provided to patients for which a public program or public or private grant funds pay for any of the charges for the care.

DHS 120.03(4)(b) (b) Contractual adjustments in the provision of health care services below normal billed charges.

DHS 120.03(4)(c) (c) Differences between a hospital’s charges and payments received for health care services provided to the hospital’s employees, to public employees or to prisoners.

DHS 120.03(4)(d) (d) Hospital charges associated with health care services for which a hospital reduces normal billed charges as a courtesy.

DHS 120.03(4)(e) (e) Bad debts.

DHS 120.03(5) (5) “Contractual adjustment” means the difference between a hospital’s full amount billed for medical services for patient services and the discounted charge or payment received by the hospital from the payer.

DHS 120.03(6) (6) “Data profile” means a summary of all submitted data and a summary of the number of records received by the department from a health care provider.

DHS 120.03(7) (7) “Data submission manual” means the department’s document specifying the procedures for submitting data, including data formats, coding specifications and instructions for editing incorrect data.

DHS 120.03(8) (8) “Data summary” means a report summarizing what the health care provider submitted, including number of records, and a listing of all questionable data records.

DHS 120.03(9) (9) “Department” means the department of health services.

DHS 120.03(9m) (9m) “Emergency department” means a distinct, dedicated area within a hospital with the staffing and resources to provide continuously available assessment, stabilization and initial management of patients presenting with conditions throughout the spectrum of acute illness and injury.

DHS 120.03(10) (10) “Employer coalition” means an organization of employers formed for negotiating terms for the purchase of health care coverage or services as a group.

DHS 120.03(11) (11) “Facility” means a hospital, freestanding ambulatory surgery center, inpatient health care facility as defined in s. 50.135 (1), Stats., hospice, community-based residential facility or rural medical center.

DHS 120.03(12) (12) “Facility level database” means a database pertaining to a facility, including aggregated utilization, staffing or fiscal data for the facility but not including data on an individual patient or data on an individual health care professional.

DHS 120.03(13) (13) “Freestanding ambulatory surgery center” or “center” means any distinct entity that is operated exclusively for the purpose of providing surgical services to patients not requiring hospitalization, that has an agreement with the federal centers for medicare and medicaid services under 42 CFR 416.25 and 416.30 to participate as an ambulatory surgery center, and that meets the conditions set forth in 42 CFR 416.25 to 416.49.

DHS 120.03(14) (14) “Gross revenue” means the total charges generated by hospitals to inpatients and outpatients for services provided regardless of the amount a hospital actually expects to collect.

DHS 120.03(15) (15) “Health care plan” means any insured or self-insured plan providing coverage of health care expenses.

DHS 120.03(16) (16) “Health care provider” has the meaning given in s. 146.81 (1), Stats., and includes a freestanding ambulatory surgery center.

DHS 120.03(17) (17) “Health care service charge” means the full amount billed for medical services before being reduced by any contractual adjustments or other discounts.

DHS 120.03(18) (18) “Hospital” has the meaning specified in s. 50.33 (2), Stats.

DHS 120.03(19) (19) “Independent review board” or “IRB” means a department board established under s. 15.195 (9), Stats., for the purpose of reviewing requests to release department data on physician office visits that, if inappropriately released, may jeopardize the privacy of individual patients or health care providers.

DHS 120.03 Note Note: Section 15.195 (9), Stats., was repealed by 2005 Wis. Act 228.

DHS 120.03(20) (20) “Individual data elements” means items of information from or derived from a uniform patient billing form or an electronic transaction and code set standard for health care.

DHS 120.03(21) (21) “Medical assistance” means the assistance program operated by the department of health services under ss. 49.43 to 49.497, Stats., and chs. DHS 101 to 108.

DHS 120.03(22) (22) “Medicare” means the health insurance program operated by the U.S. department of health and human services under 42 USC 1395 to 1395 ccc and 42 CFR ch. IV, subch. B.

DHS 120.03(23) (23) “Patient” has the meaning given in s. 153.01 (7), Stats.

DHS 120.03(24) (24) “Payer” means a party responsible for payment of a health care service charge, including an insurer or a federal, state or local government.

DHS 120.03 Note Note: Payers often reimburse health care providers a substantially lesser amount than the full charge.

DHS 120.03(25) (25) “Person” means any individual, partnership, association or corporation, the state or a political subdivision or agency of the state or of a local unit of government.

DHS 120.03(26) (26) “Physician” means a person licensed under ch. 448, Stats., to practice medicine or osteopathy.

DHS 120.03(27) (27) “Public program” means any program funded with government funds.

DHS 120.03 Note Note: Examples of public programs are Medicare under 42 USC 1395 and 42 CFR subchapter B, Badgercare under s. 49.665, Stats., Family Care under ss. 46.2805 to 46.2895, Stats., and Medical Assistance (Medicaid) under ss. 49.43 to 49.497, Stats., and chs. DHS 101 to 108 and CHAMPUS under 10 USC 1071 to 1103.

DHS 120.03(28) (28) “Public use data” means any form of data from the department’s comprehensive discharge database or facility level database that does not allow the identification of an individual from the elements released in the data files.

DHS 120.03(29) (29) “Qualified vendor” means an entity under contract with a health care provider that will submit data to the department according to formats the department specifies in its data submission manual.

DHS 120.03(30) (30) “Raw data elements” means any file, individual record, or any subset thereof, that contains information about an individual health care service provided to a single patient released by the department in public use or custom data files.

DHS 120.03 Note Note: Examples of raw data elements are any of the following:

DHS 120.03 Note a. The data files hospitals and surgery centers submit to the department each quarter.

DHS 120.03 Note b. The public-use data files the department produces.

DHS 120.03 Note c. Any custom data file produced by the department that contains individual records representing hospital discharges or surgical cases. Some customers purchase this kind of data when it is more cost-effective than purchasing the complete statewide public-use data files.

DHS 120.03 Note d. A computer printout of the individual data elements in individual records representing hospital discharges or surgical cases.

DHS 120.03(31) (31) “Reportable price increase” means a change in a hospital’s prices that, by itself or combined with other price increases during the preceding 12 months, causes the percentage increase in the hospital’s total gross revenue from patient services for the 12 months following the change to be greater than the change in the consumer price index.

DHS 120.03(32) (32) “Sign” or “signature” means any combination of words, letters, symbols or characters that is attached to or logically associated with a record and that is used by a person for the purpose of authenticating a document, including one that has been created in or transformed into an electronic format.

DHS 120.03(33) (33) “Subacute care” means goal-oriented, comprehensive, inpatient care designed for an individual who has had an acute illness, injury or exacerbation of a disease process. It is rendered immediately after, or instead of, acute hospitalization to treat one or more specific, active, complex medical conditions or to administer one or more technically complex treatments in the context of a person’s underlying long-term conditions and overall situation. Subacute care is generally more intensive than traditional nursing facility care and less intensive than acute inpatient care.

DHS 120.03(34) (34) “Trading partner agreement” means a signed, formal arrangement between a health care provider and a qualified vendor providing the transfer of data under this chapter. The agreement specifies the acceptable data formats, the edit review and verification requirements, including procedures for processing confidential patient data and the authorized signatory for the affirmation statement.

DHS 120.03(35) (35) “Uncompensated health care services” means charity care and bad debts.

DHS 120.03(36) (36) “Uniform patient billing form” means forms consistent with federal data standards for health care payment transactions.

DHS 120.03 History History: Cr. Register, December, 2000, No. 540, eff. 1-1-01; CR 01-051: cr. (9m), Register September 2001 No. 549 eff. 10-1-01; CR 03-033: am. (13), (20) and (34) Register December 2003 No. 576, eff. 1-1-04; corrections in (9) and (21) made under s. 13.92 (4) (b) 6. and 7., Stats., Register January 2009 No. 637.

subch. II of ch. DHS 120 Subchapter II — Administration

DHS 120.04 DHS 120.04 Assessments to fund the ch. 153, Stats., operations of the department and the board.

DHS 120.04(1) (1) Definitions. In this section:

DHS 120.04(1)(a) (a) “Net expenditure” means the excess of revenues over expenses.

DHS 120.04(1)(b) (b) “State fiscal year” means the 12-month period beginning July 1 and ending the following June 30.

DHS 120.04(2) (2) Estimate of expenditures. By October 1 of each year, the department shall estimate the total expenditures for the ch. 153, Stats., operations of the department and the board for the current state fiscal year from which it shall deduct all of the following:

DHS 120.04(2)(a) (a) The estimated total amount of monies related to this chapter the department will receive from user fees, gifts, grants, bequests, devises and federal funds for that state fiscal year.

DHS 120.04(2)(b) (b) The unencumbered remaining balances of the total amount of monies received through assessments, user fees, gifts, grants, bequests, devises and federal funds from the prior state fiscal year related to this chapter.

DHS 120.04(2)(c) (c) The estimated total amount to be received for purposes of administration of this chapter under s. 20.435 (1) (hi), Stats., during the fiscal year and the unencumbered remaining balance of the amount received for purposes of administration of this chapter under s. 20.435 (1) (hg), Stats., for the fiscal year.

DHS 120.04(3) (3) Calculation of assessments.

DHS 120.04(3)(a) (a) Health care providers.

DHS 120.04(3)(a)1. 1. The department shall annually assess health care providers a fee in order to fund the operations of the department and the board as authorized in s. 153.60, Stats. The department shall calculate net expenditures and resulting assessments separately for hospitals, as a group, freestanding ambulatory surgery centers, as a group, and each type of health care provider, as a group, based on the collection, analysis and dissemination of information related to each group.

DHS 120.04(3)(a)2. 2. The assessment for an individual hospital shall be based on the hospital’s proportion of the reported gross private-pay patient revenue for all hospitals for its most recently concluded fiscal year, which is that year ending at least 120 days prior to July 1.

DHS 120.04(3)(a)2m. 2m. The assessment for a hospital emergency department shall be based on the hospital’s proportion of the reported total number of emergency visits for general medical surgical and critical access hospitals. The assessment period shall cover the hospital’s most recently concluded fiscal year, which is that year ending at least 120 days prior to July 1.

DHS 120.04(3)(a)3. 3. The assessment for an individual freestanding ambulatory surgery center shall be based on the freestanding ambulatory surgery center’s proportion of the number of reported surgical procedures for all freestanding ambulatory surgery centers for the most recently concluded calendar year.

DHS 120.04(3)(a)4. 4. The board shall approve assessment amounts for health care provider classes other than hospitals and freestanding ambulatory surgery centers prior to assessment. The amounts shall equal the quotient of the total amount to be paid by the provider group divided by the number of providers licensed by and practicing in Wisconsin.

DHS 120.04(3)(a)5. 5. No health care provider that is not a facility may be assessed under this section an amount exceeding $75 per year.