DWD 80.67 History History: Cr. Register, September, 1986, No. 369, eff. 10-1-86; CR 00-181: r. and recr., Register July 2001, No. 547 eff. 8-1-01.

DWD 80.68 DWD 80.68 Payment of benefits under s. 102.59, Stats.

DWD 80.68(1) (1) Payment of benefits under s. 102.59, Stats., shall initially be made to the individual entitled to the benefits at such time as payments of primary compensation by the employer cease to be made or would have been made had there been no payment under s. 102.32 (6m), Stats., unless the preexisting disability and the disability for which primary compensation is being paid combine to result in permanent total disability.

DWD 80.68(2) (2) Payments received by an employee or dependent from an account in a financial institution or from an annuity policy where such account or annuity policy are established through settlement of the claim for primary compensation, shall be considered payments by the employer or insurance carrier.

DWD 80.68(3) (3) Payments under s. 102.59, Stats., shall be on a periodic basis but subject to s. 102.32 (6m) and (7), Stats.

DWD 80.68 Note Note: This rule is adopted to insure the solvency of the work injury supplemental benefit and to insure the protection of dependents as of the date of death of the employee with the preexisting disability.

DWD 80.68 History History: Cr. Register, September, 1986, No. 369, eff. 10-1-86; CR 07-019: am. (1) and (3), Register October 2007 No. 622, eff. 11-1-07.

DWD 80.70 DWD 80.70 Malice or bad faith.

DWD 80.70(1) (1) An employer who unreasonably refuses or unreasonably fails to report an alleged injury to its insurance company providing worker’s compensation coverage, shall be deemed to have acted with malice or bad faith.

DWD 80.70(2) (2) An insurance company or self-insured employer who, without credible evidence which demonstrates that the claim for the payments is fairly debatable, unreasonably fails to make payment of compensation or reasonable and necessary medical expenses, or after having commenced those payments, unreasonably suspends or terminates them, shall be deemed to have acted with malice or in bad faith.

DWD 80.70 History History: Cr. Register, September, 1982, No. 321, eff. 10-1-82.

DWD 80.72 DWD 80.72 Health service fee dispute resolution process.

DWD 80.72(1) (1) Purpose. The purpose of this section is to establish the procedures and requirements for resolving a dispute under s. 102.16 (2), Stats., between a health service provider and an insurer or self-insured employer over the reasonableness of a fee charged by the health service provider relating to the examination or treatment of an injured worker, and to specify the standards that health service fee data bases must meet for certification by the department.

DWD 80.72(2) (2) Definitions. In this section:

DWD 80.72(2)(a) (a) “ADA” means American dental association.

DWD 80.72(2)(b) (b) “Applicant” means the person requesting certification of a data base.

DWD 80.72(2)(c) (c) “Certified” means approved by the department for use in determining the reasonableness of fees.

DWD 80.72(2)(d) (d) “CPT code” means the American medical association’s 1992 physicians’ current procedural terminology.

DWD 80.72 Note Note: This volume is on file in the offices of the secretary of state and the legislative reference bureau, and in the worker’s compensation division of the department, GEF I, room 161, 201 E. Washington Ave., Madison, Wisconsin. Copies can be obtained from local textbook stores or from the American medical association, order department: OP054192, P.O. Box 10950, Chicago, IL 60601.

DWD 80.72(2)(e) (e) “Data base” means a list of fees for procedures compiled and sorted by CPT code, ICD-9-CM code, ADA code, DRG code, or other similar coding which is systematically collected, assembled, and updated, and which does not include procedures charged under medicare.

DWD 80.72(2)(f) (f) “DRG” means a diagnostic related group established by the federal health care financing administration.

DWD 80.72(2)(g) (g) “Dispute” means a disagreement between a health service provider and an insurer or self-insured employer over the reasonableness of a fee charged by a health service provider where the insurer or self-insured employer refuses to pay part or all of the fee.

DWD 80.72(2)(h) (h) “Fee” or “health service fee” means the amount charged for a procedure by a health service provider.

DWD 80.72(2)(i) (i) “Formula amount” means the mean fee for a procedure plus 1.4 standard deviations from that mean as shown by data from a certified data base.

DWD 80.72(2)(j) (j) “ICD-9-CM” means the commission on professional and hospital activities’ international classification of diseases, 9th revision, clinical modification.

DWD 80.72 Note Note: This volume is on file in the offices of the secretary of state and the legislative reference bureau, and in the worker’s compensation division of the department, GEF I, room 161, 201 E. Washington Ave., Madison, Wisconsin. Copies can be obtained from local textbook stores, or from superintendent of documents, U.S. government printing office, Washington, D.C., 20402, (stock number 917014000001.

DWD 80.72(2)(k) (k) “Procedure” or “health service procedure” means any treatment of an injured worker under s. 102.42, Stats.

DWD 80.72(2)(L) (L) “Provider” or “health service provider” includes a physician, podiatrist, psychologist, optometrist, chiropractor, dentist, physician’s assistant, advanced practice nurse prescriber, therapist, medical technician, or hospital.

DWD 80.72(2)(m) (m) “Self-insurer” means an employer who has been granted an exemption from the duty to insure under s. 102.28 (2), Stats.