WISCA members shared an interest in monitoring prior authorization policy changes in the state. The following is a summary of recent developments:

1) The State’s Joint Committee on Finance recently met to review budget items included in Governor Ever’s state budget.  On May 8 they voted on party lines to remove what were considered “policy” items from the budget.  These include 2 proposals from the Office of the Commissioner of Insurance.

2) Assembly Health Committee Chair Clint Moses (R-Menomonie) announced at plans to introduce legislation that would reform prior authorization process in the state.  His goals are to have greater consistency among insurers, speed up the process in order to prevent any care delays and reduce provider burdens.

On Friday, April 18, the Wisconsin Supreme Court in a 4-3 decision upheld Gov. Tony Evers’ 2023 partial veto that extended annual school funding increases until the year 2425 by striking numerals and punctuation in the budget bill. The GOP-controlled legislature had passed a two-year increase in schools aids. Gov. Evers used his partial veto authority to, in addition to issued other partial vetoes, change a sentence in the budget bill from “for the 2023-24 school year and the 2024-25 school year” to read “for 2023-2425.” By doing so, he was able to extend these annual funding increases until the year 2425.

Regarding the ruling Gov. Evers said, “This decision is great news for Wisconsin’s kids and our public schools, who deserve sustainable, dependable, and spendable state support and investment.” Scott Manley, executive vice president of government relations with Wisconsin Manufacturers and Commerce, which had filed the lawsuit, described the veto and the court’s upholding of it as “an embarrassing example of executive overreach, and an equally embarrassing example of a hyper partisan judicial ruling.”

This decision significantly affects what had been the general understanding of gubernatorial veto powers in Wisconsin and will dramatically affect how the Wisconsin Legislature proceeds as it considers the next two-year state spending plan. Lawmakers will proceed with caution as they determine how to now proceed in light of this new understanding of gubernatorial veto powers.

Senator Jesse James and Representative Callahan introduced a bill that would require certification for surgical technologists. The bill would prohibit hospitals and ASCs from employing or otherwise retaining any individual to perform surgical technology services unless the individual is qualified.

In order for a surgical technician to be qualified an individual must satisfy one of the following criteria:

1) Successfully completing a training program for surgical technology in connection with an individual’s military service, or

2) Successfully completing an accredited educational program for surg techs and holding and maintaining a certification as a surg tech from a national and accredited certifying body.

The bill provides that a hospital or ASC may employ or otherwise retain the services on an individual to perform surgical technology services during the 24-month period that immediately follows the individual’s successful completion of an educational program for surg techs.

The bill also provides that these requirements do not apply to a licensed health care provider who may provide surgical technology services within their scope of practice. If you have questions or concerns about the bill please contact Andy at engel@hamilton-consulting.com

ASCA is planning to introduce the Medicare Beneficiary Co-Pay Fairness Act, a new federal legislation aimed at addressing the co-pay penalty faced by Medicare beneficiaries when seeking care at ASC's. This legislative effort follows extensive discussions with congressional supporters in the 118th Congress and is backed by key sponsors, including Representatives Mike Kelly (PA-16) and Robert Menendez, Jr. (PA-18), and Senators Bill Cassidy (R-LA) and Richard Blumenthal (D-CT).

The upcoming bill, which draws from language used in ASCA's previous Outpatient Surgery Quality and Access Act, seeks to alleviate the financial burden of co-pays for Medicare beneficiaries. ASCA is working to build a coalition of supporting organizations to send letters of support to key committees, including the House Energy & Commerce, Ways & Means, Senate Finance, and HELP committees.

WISCA has joined the coalition and will share information with members to help reach out to your legislators to help grow support.  More details are available on the documents linked below, including a one-pager outlining the co-pay penalty issue.

Medicare Beneficiary Co-Pay Fairness Act Draft.pdf

Issue Brief Copay Cap 2024-12-11.pdf

The 2025-2026 legislative session is now in full swing commencing in earnest with the Governor’s bi-annual budget address. The Governor has deemed this the “year of the kid” as his address focused on education, clean drinking water and a tax cut plan. Governor Evers also honed in on a message that went after prescription drug costs and health insurers.  Republican legislators largely dismissed the Governor’s plans and have stated they will once again craft a budget of their own focused on using the Wisconsin’s $4 billion surplus to provide an extensive tax cut.

Highlights from the Governor’s provisions relating to health insurance:

• Require OCI to establish a framework for auditing high rates of health insurance claims denials.

• OCI audit of insurers with claims denial rates above a certain percentage, determined by OCI, and require corrective action plans based on the audit findings.

• Allow OCI to enforce corrective action plans through fines, forfeiture or other mechanisms.

• Prior Authorization Exemption Requirements (Gold Carding)

• Require OCI to develop parameters for when services are exempt from requiring prior authorization; providers who receive prior authorization approvals above a certain rate would be exempt from requiring prior authorization for services provided or 
  recommended by them.

• Prior Authorization Transparency

• Require insurers to provide consumers with a list of treatments and services covered by health plans offered by the health insurer which require prior authorization.

• Create a Public Intervenor Office within OCI to provide information and assistance to consumers in receiving better claim outcomes. Consumers whose health insurance claims are denied would be assisted with appeals and other legal actions to pursue coverage for health care services.

While most of these provisions will get removed by the legislature from the state budget, some of them, like the prior authorization requirements, will likely be proposed in bill form by a bi-partisan coalition. WISCA will follow those developments closely and will voice support for provisions that improve ASC’s ability to serve their patients.

- Andy Engel, Hamilton Consulting

ASCA Recommends Additions to CMS List of Covered Procedures

On February 28, ASCA submitted codes in response to the Centers for Medicare & Medicaid Services’ ASC Covered Procedures List (ASC-CPL) Pre-Proposed Rule Recommendation Request. Based on feedback from ASCA members, including its cardiovascular working group, ASCA submitted the following:

Cardiovascular Codes

• Electrophysiology Studies and Ablations: 93619, 93620, 93624, 93642, 93650, 93653, 93654, 93656 and 93724
• Cardioversion and Transesophageal Echocardiogram: 92960, 93312 and 93318
• Percutaneous Coronary Intervention (PCI): C9602, C9604 and C9607

Spine Codes

• Posterior Lumbar Interbody Fusion: 22630
• Combined Posterior Lumbar and Posterior Lumbar Interbody Fusion: 22633

Vascular Code

• Vascular Embolization or Occlusion: 37244

You can read more about the ASC-CPL Pre-Proposed Rule Recommendation Request process in this Digital Debut. Contact Kara Newbury at knewbury@ascassociation.org with any questions.

Medicare Physician Payment Cuts

Last week, Rep. Murphy highlighted the impact of ongoing Medicare payment cuts, including a 2.83% January reduction, on physician practices, citing a 33% drop in inflation-adjusted reimbursements since 2001 against a 59% rise in practice costs. His re-introduced Medicare Patient Access and Practice Stabilization Act, aiming to reverse cuts and provide a 2% increase, was excluded from the House Rules Committee's "clean" CR, despite prior optimism for March 14 inclusion.

Co-Pay Cap Legislation

Reps. Rob Menendez and Mike Kelly are expected to co-lead the introduction of the co-pay cap bill, following staff approval. David has engaged extensively with their respective staff. Final confirmation is anticipated this week, with optimism for introduction by March's end, preceding Reconciliation.

WISCA works closely with our national association partner – the Ambulatory Surgery Center Association (ASCA) – on advocacy and other issues important to our members. In fact, the WISCA Government Affairs Team joins a national ASCA state chapter call twice a month for a federal regulatory and legislative briefing and closely follows their published Government Affairs Updates. Here is the latest federal government affairs news from ASCA:

• Final ACS Rule Update:  On November 1, the Centers for Medicare & Medicaid Services (CMS) released its 2025 final payment rule for ASCs and hospital outpatient departments (HOPD). Of note, CMS declined to add any of the surgical procedures requested by ASCA to the ASC Covered Procedures List (ASC-CPL) for 2025. CMS will continue to use the hospital market basket (HMB) as the ASC inflation update factor for 2025, although it is unclear whether that policy will continue further. This results in an effective update of 2.9 percent for ASCs—a combination of a 3.4 percent inflation update based on the HMB and a productivity reduction of 0.5 percentage points mandated by the Affordable Care Act. This is an increase of 0.3 percent from the proposed rule. Please note that this is an average and updates might vary significantly by code and specialty. CMS finalized the addition of 21 procedures to the ASC-CPL, including 19 dental codes that were included in the proposed rule. In addition, the agency finalized the addition of the following two adipose-derived regenerative cell (ADRC) therapy codes (short descriptor in parentheses):
• • 0717T (Adrc ther prtl rc tear)
  • 0718T (Adrc ther prtl rc tear njx)

Regarding the ASC Quality Reporting (ASCQR) Program, CMS is finalizing the adoption of the following measures:

• The Facility Commitment to Health Equity (FCHE) measure beginning with the CY 2025 reporting period/CY 2027 payment determination;
• The Screening for Social Drivers of Health (SDOH) measure beginning with voluntary reporting in the CY 2025 reporting period followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination; and
• The Screen Positive Rate for Social Drivers of Health (SDOH) measure beginning with voluntary reporting in the CY 2025 reporting period followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination.

ASCA will continue to analyze the 1,734-page final rule in detail and provide more information and resources soon, including its proprietary rate calculator, to help ASC operators understand the impact this rule will have on their centers.

• Medicare Physician Fee Schedule Final Rule: On November 1, the Centers for Medicare & Medicaid Services (CMS) released final policy updates for the 2025 Medicare Physician Fee Schedule (MPFS). The rule includes a 2.83 percent reduction to the physician conversion factor, which was expected due to the expiration of a one-year 1.68 percent increase passed as part of the Consolidated Appropriations Act, 2024 (CAA). Physicians have already organized in support of the recently introduced Medicare Patient Access and Practice Stabilization Act of 2024, which would eliminate the forthcoming cut and provide a small inflationary update to physician rates. Congress has had to intervene every year since 2021 to mitigate cuts in the MPFS. ASCA submitted formal comments in response to the MPFS proposed rule, primarily following the advocacy of the specialty societies that work in surgery centers.
• Election Update: Regarding congressional races, Republicans secured a majority in the Senate, winning 53 seats to the Democrats’ 47. The battle for control of the House, which requires 218, has been won by Republicans. Currently, Republicans have 218 seats, while Democrats have 212. Five house races have yet to be called.
• • ASCAPAC: ASCA’s Political Action Committee (ASCAPAC) contributed to 17 Representatives and Senators in the 118^th Congress. All ASCAPAC recipients eligible for reelection in the 118^th Congress have successfully won their races, as called by the Associated Press. No PAC-recipient Senators from the 118th Congress were up for reelection this year.
  • Federal Legislation: Regarding the cosponsors of H.R.972—Outpatient Surgery Quality and Access Act of 2023—100% of candidates seeking reelection have done so, with the exception of Rep. Miller-Meeks from Iowa’s 1^st District, whose race is still pending official results from the Associated Press.

Following election night, state lawmakers traditionally convene in partisan caucus – Assembly GOP Caucus, Assembly DEM Caucus; Senate GOP Caucus; and Senate DEM Caucus – to choose their respective leadership teams for the new legislative session. This election cycle was no exception, as all four partisan caucuses have or will meet to elect their leaders for the 2025-26 session.

There were no huge surprises, as most of the leadership team members from all four caucuses from the 2023-24 session retained their positions. However, there were some developments of note. Most prominently, Sen. Chris Kapenga (R-Pewaukee) decided not seek reelection for Senate President, and Sen. Mary Felzkowski (R-Tomahawk) was elected to the post. In addition, Rep. Scott Krug (R-Nekoosa) was selected as Assembly Assistant Majority Leader to replace a retiring colleague, and Sen. Mark Spreitzer (D-Beloit) was chosen as Senate Minority Caucus Chair, after serving in a lower leadership position last session. Please find the full legislative leadership results below:

Assembly Republicans

• Assembly Speaker – Rep. Robin Vos (R-Rochester)

• Assembly Majority Leader – Rep. Tyler August (R-Walworth)

• Assembly Assistant Majority Leader – Rep. Scott Krug (R-Nekoosa)

• Assembly Speaker Pro Tempore – Rep. Kevin Peterson (R-Waupaca)

• Assembly Majority Caucus Chair – Rep. Rob Summerfield (R-Bloomer)

• Assembly Majority Caucus Vice Chair – Rep. Cindi Duchow (R-Delafield)

• Assembly Majority Caucus Secretary – Rep. Nancy VanderMeer (R-Tomah)

• Assembly Majority Caucus Sergeant at Arms – Rep. Treig Pronschinske (R-Mondovi)

Senate Republicans

• Senate Majority Leader – Sen. Devin LeMahieu (R-Oostburg)

• Senate President – Sen. Mary Felzkowski (R-Tomahawk)

• Senate Assistance Majority Leader – Sen. Dan Feyen (R-Fond du Lac)

• Senate President Pro Tempore – Sen. Patrick Testin (R-Stevens Point)

• Senate Majority Caucus Char – Sen. Van Wanggaard (R-Racine)

• Senate Majority Caucus Vice-Chair – Sen. Rachel Cabral-Guevara (R-Appleton)

Senate Democrats

• Senate Minority Leader – Sen. Dianne Hesselbein (D-Middleton)

• Senate Assistant Minority Leader – Sen. Jeff Smith (D-Eau Claire)

• Senate Minority Caucus Chair – Sen. Mark Spreitzer (D-Beloit)

• Senate Minority Vice Caucus Chair – Sen.  Dora Drake (D-Milwaukee)

The Assembly Democratic Caucus will meet later this week to choose their leadership roster.

Wisconsin lived up to both its “Purple State” and its ticket-splitting reputation on election night (Nov. 5) as election results were razor thin across the ballot.  Former President Trump won the state by 30,000 votes, roughly 0.9% of the vote.  This is only the second time in the last 40 years the state has voted Republican for President, the first was also for Trump in 2016.  Conversely, Democrat US Senator Tammy Baldwin was re-elected by a very narrow margin, roughly 29,000 votes.   

There was also uncertainty with state legislative races heading into election night, mostly due to the election being held under new legislative maps. The State Assembly entered the night with a 64-35 Republican majority.  Most pundits expected the GOP to lose numerous seats, with some even predicting Democrats taking the majority.  However, once all the votes were counted, Assembly Republicans maintained 54-45 seat majority heading into the 2025-26 legislative session.

In the State Senate, Republicans lost all 4 contested seats and will enter the new session with a reduced 18-15 majority – down from their current 22-11 seat majority. Of note, Republican incumbent Senator Joan Ballweg (R-Markeson) lost her re-election battle after her 60% GOP seat was redistricted into a 45% GOP seat.  Similarly, Republican incumbent Senator Duey Stroebel (R-Saukville) lost his re-election race after he was redistricted out of his 70% GOP seat into a 49.5% seat.  The main take away from the election is that with their 4-seat pick-up, Democrats have put themselves into position to contest for the majority in 2026 election cycle.

The WISCA Government Affairs Team would like to thank every member who provided input on the development of WISCA’s 2025-26 Legislative Agenda – both at our monthly advocacy calls and through our member survey. With your valuable input, we were able to develop a broad legislative agenda that includes specific legislative goals. Please find below an overview of the 2025-26 WISCA Legislative Agenda:

• Exploration of Medicaid reimbursement increases.  We want to study MA as a payer to see if there are procedures that stand out for needing a higher reimbursement rate, as well as understanding what level of increase would be needed. 
• Every session we expect to see Workers Compensation bills. In the most recent sessions, some have argued on behalf of a health care fee schedule which would institute maximum payment amounts. In addition to opposing a fee schedule WISCA will monitor the Workers Compensation Council.
• We are expecting to see legislation from the Wisconsin Medical Society relating to prior authorization reform.  On a recent call ASCs voiced their frustrations with certain aspects of prior authorization. WISCA will have the opportunity to be part of a coalition that supports these reforms.
• Nationally ASCA has seen an uptick in bills imposing facility fees on ASCs.  We will monitor legislative activity to make sure such an effort doesn’t take hold in Wisconsin. 

Legislation to Watch:

• Advanced Practice Registered Nurse bill – Broader legislation that could impose a collaborative agreement requirement on nurse anesthetists that would be burdensome to certain ASCs.
• DSPS licensing – Any legislation that would improve the process to ensure health care professionals are licensed in a timelier manner.
• Video recording devices—Legislation that would require providers to record surgery at a patient’s request.

·     Transparency – Legislation targeting price transparency for hospitals, and potentially ASCs.