Wisconsin 2023-2024 Regular Session

Wisconsin Assembly Bill AB1187 Compare Versions

Only one version of the bill is available at this time.

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1	1	LRB-4736/1
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3	3	2023 - 2024 LEGISLATURE
4	4	2023 ASSEMBLY BILL 1187
5	5	April 9, 2024 - Introduced by Representative MCGUIRE. Referred to Committee on
6	6	Insurance.
7	7	*AUTHORS SUBJECT TO CHANGE*
8	8	AN ACT to amend 609.32 (2) (a); and to create 609.32 (2) (am) of the statutes;
9	9	relating to: provisional approval as a participating provider in a defined
10	10	network health plan.
11	11	Analysis by the Legislative Reference Bureau
12	12	This bill requires defined network plans to issue provisional approvals to
13	13	individual health care providers who submit a completed application, contract, or
14	14	letter of intent to become a participating provider in a plan's network and who agree
15	15	to the plan's terms for providers of the same type. Defined network plans are health
16	16	benefit plans that require or provide incentives for their enrollees to use providers
17	17	that are managed, owned, under contract with, or employed by the insurer that offers
18	18	the health benefit plan. Defined network plans include such plans as health
19	19	maintenance organizations, including, for purposes of this bill, health maintenance
20	20	organizations that serve Medical Assistance recipients, and some preferred provider
21	21	plans. Current law requires defined network plans to develop a process for selecting
22	22	and establishing minimum professional requirements for participating providers,
23	23	which must include verifying providers' credentials and the history of any liability
24	24	claims made against providers. The bill requires a defined network plan to ensure
25	25	that any entity that it contracts with to perform review or verification also complies
26	26	with the bill. The bill requires defined network plans to notify providers of the final
27	27	approval or denial of participating provider status in writing along with the effective
28	28	date of the approval or denial.
29	29	A provisional approval under the bill allows the applicant provider to provide
30	30	services and obtain reimbursement as if the applicant is a participating provider
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33	33	3 - 2 -2023 - 2024 Legislature LRB-4736/1
34	34	JPC:cjs
35	35	ASSEMBLY BILL 1187
36	36	under the plan before the applicant attains final approval to be a participating
37	37	provider effective on the date the plan receives the provider's application, contract,
38	38	or letter of intent. The bill prohibits a plan from recouping any payments it makes
39	39	to a provider during the period the provisional approval is effective. If the plan
40	40	ultimately denies the provider's application, contract, or letter of intent, the plan
41	41	must reimburse the provider for services provided during the period the provisional
42	42	approval was effective for at least two weeks following the date that the provider's
43	43	application, contract, or letter of intent is denied.
44	44	The people of the state of Wisconsin, represented in senate and assembly, do
45	45	enact as follows:
46	46	SECTION 1. 609.32 (2) (a) of the statutes is amended to read:
47	47	609.32 (2) (a) A defined network plan shall develop a process for selecting
48	48	participating providers, including written policies and procedures that the plan uses
49	49	for review and approval of providers. After consulting with appropriately qualified
50	50	providers, the plan shall establish minimum professional requirements for its
51	51	participating providers. The process for selection shall include verification of a
52	52	provider's license or certificate, including the history of any suspensions or
53	53	revocations, and the history of any liability claims made against the provider. The
54	54	defined network plan shall issue a provisional approval to an individual provider
55	55	who submits a completed application, contract, or letter of intent to become a
56	56	participating provider and who agrees to comply with the terms of the plan that are
57	57	applicable to providers of the same type as the applicant. A health maintenance
58	58	organization that serves Medical Assistance recipients shall comply with this
59	59	paragraph when considering the selection of a provider who is certified by the
60	60	department of health services under the Medical Assistance program. A defined
61	61	network plan shall ensure that any entity it contracts with to perform review or
62	62	verification of a provider's application, contract, or letter of intent to become a
63	63	participating provider complies with this paragraph. A defined network plan shall
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81	81	18 - 3 -2023 - 2024 Legislature
82	82	LRB-4736/1
83	83	JPC:cjs
84	84	SECTION 1
85	85	ASSEMBLY BILL 1187
86	86	notify a provider in writing of the final approval or denial of an application, contract,
87	87	or letter of intent to become a participating provider and the effective date of the final
88	88	approval or denial.
89	89	SECTION 2. 609.32 (2) (am) of the statutes is created to read:
90	90	609.32 (2) (am) All of the following apply to a provisional approval issued under
91	91	par. (a):
92	92	1. The provisional approval shall allow the provider to provide services and
93	93	obtain reimbursement under the defined network plan as if the provider was a
94	94	participating provider before the provider attains final approval or denial as a
95	95	participating provider.
96	96	2. The provisional approval is effective on the date the defined network plan
97	97	receives the application, contract, or letter of intent.
98	98	3. A defined network plan may not recoup any payments to a provider made
99	99	during the period a provisional approval is effective.
100	100	4. A defined network plan shall reimburse a provider for services provided
101	101	during the period the provisional approval was effective for at least 2 weeks following
102	102	the date that the provider's application, contract, or letter of intent is denied.
103	103	SECTION 3.0Initial applicability.
104	104	(1) This act first applies to applications, contracts, and letters of intent to
105	105	become a participating provider received by a defined network plan on the effective
106	106	date of this subsection.
107	107	SECTION 4.0Effective date.
108	108	(1) This act takes effect on the first day of the 4th month beginning after
109	109	publication.
110	110	(END)
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