Reasonableness of Fee

Reasonableness of Fee Dispute Resolution Request Form (WKC-9498)

Reasonableness of fee provisions can be found in s. 102.16 (2), Wis. Stats., and are further detailed in Wis. Admin. Code DWD 80.72.

The provider must file with the department within six (6) months from the date they first received notice from the insurer, or self-insured employer, refusing to pay the provider's bill.

Reasonableness of Fee Dispute (Guide Letter GL94):

When there is a dispute between a health care provider and an insurer or self-insured employer regarding reasonableness of fees for treatment provided to an injured worker, the provider may request the Department resolve the dispute.

• For the Department to determine whether or not a fee is reasonable under s. 102.16 (2), Stats., a provider shall file a written request to the department to resolve the dispute.
• A request by a provider shall include copies of all correspondence, including billing statements and doctor's notes, in its possession related to the fee dispute.
• The department shall notify the insurer, or self-insured, when a request to resolve the dispute is submitted that the insurer, or self-insured, has 20 days to file an answer or a default judgment may be ordered.
• The insurer, or self-insured, shall file an answer with the department, and send a copy to the provider, within 20 days from the date of the department's notice of dispute. The answer shall include:
  • Copies of any prior correspondence relating to the fee dispute which the provider has not already filed.
  • Information from a certified data base on fees charged by other providers for comparable services or procedures which clearly demonstrates that the fee in dispute is beyond the formula amount for the service or procedure within the provider's geographical area.
  • An explanation of why the service provided in the disputed case is not more difficult or complicated than what is usually expected.
• The department shall examine the material submitted by all parties and issue its order resolving the dispute.

NOTE: By law, when the provider files the dispute application with the department, the provider must, at the same time, send or deliver a copy of all materials submitted with the dispute application to the insurer or self-insured employer who is refusing to pay for the treatment it considers unnecessary.