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2009 Wisconsin Act 146 – Assembly Bill 614

Impact of the Legislation on Patient Care Clients and Members

Health care costs increase when employers and employees spend more for health care services than necessary.  Those expenditures can occur when there is over-utilization or when the costs per unit of service are higher than they should be.  Amounts paid for the same procedure (colonoscopy or MRI) can vary significantly from provider to provider in the same market in the same network.  When cost information is available to employees, they will make smart health care purchasing decisions.

This Legislation creates a requirement for all providers to share relevant and heretofore secret information with consumers.  Patient Care has been a pioneer in this effort, researching and communicating specific cost and quality information to Members for over 5 years.  Hundreds of Members per month receive comparative information from their Advocate along with a consultative explanation of the information.  Over 50% of them move to lower cost providers based on the process, saving money for themselves, their families and their employers.

Legislation Overview:

This legislation will go into effect on January 1, 2011.

Providers (doctors, dentists, pharmacists, clinics, ambulatory surgical centers, etc.) must supply the following:

  • Upon request, for any health care service or test performed at their office:
    • Median billed charge
    • Any publicly reported quality information about the provider regarding the requested health care service or test, as compared to other providers
  • A single document for the top 25 conditions presented at their office:
    • Median billed charge
    • Medicare payment to the provider
    • Average allowable payment from a 3rd party payor

Hospitals must supply the following:

  • A single document for the top 75 diagnosis groups and the top 75 outpatient surgical procedures:
    • Median billed charge
    • Average allowable payment under Medicare
    • Average allowable payment from a 3rd party payor

A penalty of $250 per violation may be required of providers and hospitals for non-compliance.

Self-funded plans of public entities (state, county, city, village, town or school district), upon request, must supply an estimate of the insured’s total out-of-pocket costs (according to their health plan) for the service requested in their region.  Individuals requesting this information may be required to provide:

  • Provider name
  • Facility name
  • Service date of the procedure or test
  • CPT code for the procedure or test

Conclusion:

This legislation will make our work for Wisconsin Members easier.  The data will be more readily available.  However, it will still be complex and difficult for Members to access and understand.  Having an Advocate to explain the information and relate it to a Member’s decision will link data with decisions, and continue to help them become better health care consumers.

For more information, contact Emily Penner at 414-274-3359 or epenner@patientcare4u.com