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.