102.425 (4m) as to the reasonableness of the prescription drug charge or, if such a determination has not yet been made, the department may notify, or direct the insurer or self-insured employer to notify, the pharmacist or practitioner dispensing the prescription drug under s. 102.425 (4m) (b) that the reasonableness of the prescription drug charge is in dispute. The department shall deny payment of a prescription drug charge that the department determines under s. 102.425 (4m) to be unreasonable. A pharmacist or practitioner and an insurer or self-insured employer that are parties to a dispute under this paragraph over the reasonableness of a prescription drug charge are bound by the department’s determination under s. 102.425 (4m) on the reasonableness of the disputed prescription drug charge, unless that determination is set aside, reversed, or modified by the department under s. 102.425 (4m) (e) or is set aside on judicial review as provided in s. 102.425 (4m) (e). (2) (a) Except as provided in this paragraph, the department has jurisdiction under this subsection, sub. (1m) (a), and s. 102.17 to resolve a dispute between a health service provider and an insurer or self-insured employer over the reasonableness of a fee charged by the health service provider for health services provided to an injured employee who claims benefits under this chapter. A health service provider may not submit a fee dispute to the department under this subsection before all treatment by the health service provider of the employee’s injury has ended if the amount in controversy, whether based on a single charge or a combination of charges for one or more days of service, is less than $25. After all treatment by a health service provider of an employee’s injury has ended, the health service provider may submit any fee dispute to the department, regardless of the amount in controversy. The department shall deny payment of a health service fee that the department determines under this subsection to be unreasonable. (am) A health service provider and an insurer or self-insured employer that are parties to a fee dispute under this subsection are bound by the department’s determination under this subsection on the reasonableness of the disputed fee, unless that determination is set aside on judicial review as provided in par. (f). (b) An insurer or self-insured employer that disputes the reasonableness of a fee charged by a health service provider or the department under sub. (1m) (a) or s. 102.18 (1) (bg) 1. shall provide reasonable written notice to the health service provider that the fee is being disputed. After receiving reasonable written notice under this paragraph or under sub. (1m) (a) or s. 102.18 (1) (bg) 1. that a health service fee is being disputed, a health service provider may not collect the disputed fee from, or bring an action for collection of the disputed fee against, the employee who received the services for which the fee was charged. (c) After a fee dispute is submitted to the department, the insurer or self-insured employer that is a party to the dispute shall provide to the department information on that fee and information on fees charged by other health service providers for comparable services. The insurer or self-insured employer shall obtain the information on comparable fees from a database that is certified by the department under par. (h). Except as provided in par. (e) 1., if the insurer or self-insured employer does not provide the information required under this paragraph, the department shall
May 22, 2026, are designated by NOTES. (Published 5-22-26)
102.16
WORKER’S COMPENSATION
determine that the disputed fee is reasonable and order that it be paid. If the insurer or self-insured employer provides the information required under this paragraph, the department shall use that information to determine the reasonableness of the disputed fee. NOTE: Par. (c) is affected by 2025 Wis. Act 15 eff. on the day after the notice from the department of health services under 2025 Wis. Act 15 s. 9119 (4) (b) 1. is published by the legislative reference bureau in the Wisconsin Administrative Register, except that, if the notice is not published before August 1, 2027, the treatment of par. (c) is void. As affected, par. (c) reads: (c) 1. Except as provided in subd. 2., after a fee dispute is submitted to the department, the insurer or self-insured employer that is a party to the dispute shall provide to the department information on that fee and information on fees charged by other health service providers for comparable services. The insurer or self-insured employer shall obtain the information on comparable fees from a database that is certified by the department under par. (h) 2. Except as provided in par. (e) 1., if the insurer or self-insured employer does not provide the information required under this subdivision, the department shall determine that the disputed fee is reasonable and order that it be paid. If the insurer or self-insured employer provides the information required under this subdivision, the department shall use that information to determine the reasonableness of the disputed fee under par. (d). 2. After a dispute is submitted to the department concerning the applicability of s. 102.423 to the fee or the amount of the fee under s. 102.423, the insurer or self-insured employer that is a party to the dispute shall provide to the department information on that fee, information on the medical records and bill provided to the insurer or self-insured employer in connection with that fee, and any other information requested by the department. If the insurer or selfinsured employer does not provide the information required under this subdivision to confirm the applicability of s. 102.423, the department shall determine that s. 102.423 does not apply to the fee and may adjudicate the fee under subd. 1. If the insurer or self-insured employer does not provide the information required under this subdivision to determine that the amount of the fee exceeds the allowable amount under s. 102.423, as applicable, the department shall determine that the disputed fee is allowable and order that it be paid. If the insurer or self-insured employer provides the information required under this subdivision, the department shall use that information to determine if s.