Gov. Evers: "We are going to make Wisconsin the first state in America to start auditing insurance companies over denying healthcare claims." -

A Call for Healthcare Industry Accountability

Governor Tony Evers of Wisconsin has unveiled a comprehensive and ambitious plan to overhaul the state’s healthcare landscape, directly addressing widespread frustrations with insurance companies, escalating prescription drug costs, and barriers to accessing timely and affordable care. Embedded within his 2025-27 Biennial Budget proposal, these sweeping reforms aim to make Wisconsin a national leader in holding insurance companies accountable, protecting consumers, and ensuring that healthcare is accessible to all residents, regardless of their income or location.

The governor’s proposals are rooted in the experiences of countless Wisconsinites who have struggled with the complexities and often-unjust practices of the healthcare industry. These struggles include navigating confusing insurance policies, facing unexpected claim denials, battling lengthy prior authorization processes, encountering surprise medical bills, and grappling with the soaring costs of prescription medications. Governor Evers’ plan seeks to dismantle these barriers, creating a system where healthcare is a right, not a privilege, and where the focus is on patient well-being rather than corporate profits.

The Core Issues: A System Failing Wisconsin Residents

At the heart of Governor Evers’ proposals lies a deep understanding of the systemic issues plaguing the healthcare industry. These issues, experienced by individuals across the state, paint a picture of a system that often prioritizes profits over people:

Insurance Claim Denials: Many Wisconsinites find themselves in a frustrating battle with insurance companies over denied claims. They are often left without clear explanations for these denials, leaving them to navigate a complex appeals process or, worse, shoulder the burden of unexpected medical bills. The lack of transparency and accountability in the claims process leaves many feeling powerless and cheated by a system they rely on for their health and well-being.
Prior Authorization Hurdles: The requirement for prior authorization, where insurance companies must approve medical procedures or medications before they are covered, has become a significant obstacle to timely care. This process often involves lengthy delays, forcing patients to wait weeks or even months for necessary treatments. Doctors and healthcare professionals find their medical judgment overridden by insurance company protocols, leading to frustration and, in some cases, worsening health outcomes for patients.
Surprise Medical Bills: Unexpected medical bills, often stemming from out-of-network care or services not clearly covered by insurance, can be financially devastating for individuals and families. These surprise bills can arise even when patients believe they have followed all the necessary steps to ensure their care is covered, leaving them with unexpected debt and a sense of betrayal by the healthcare system.
Prescription Drug Price Gouging: The escalating costs of prescription drugs have made it increasingly difficult for many Wisconsinites to afford the medications they need to manage their health. Price gouging by pharmaceutical companies, coupled with complex insurance formularies and high copays, forces individuals to make difficult choices between their health and other essential needs.
Limited Access to Care: Access to timely and convenient healthcare is a challenge for many, particularly those in rural communities. Long travel distances to healthcare facilities, coupled with lengthy wait times for appointments, can deter individuals from seeking the care they need. This lack of access can lead to delayed diagnoses, worsening health conditions, and a widening gap in health equity across the state.
Lack of Mental Health Parity: Individuals experiencing a mental health crisis often face additional barriers to care, including insurance companies requiring pre-approval for in-patient mental health services. This can delay or prevent access to critical, life-saving care at a time when it is most urgently needed.

Governor Evers’ Bold Solutions: A Multi-Pronged Approach

Governor Evers’ 2025-27 Executive Budget proposes a multi-faceted approach to address these systemic challenges, aiming to create a more equitable, transparent, and patient-centered healthcare system. The key components of his plan include:

1. Auditing Insurance Companies for Claim Denials:

Governor Evers proposes a groundbreaking initiative to make Wisconsin the first state in the nation to audit insurance companies specifically for their claim denial rates. This bold move signals a commitment to holding insurance companies accountable for their decisions and ensuring that claims are not being unjustly denied.

The Audit Process: Under this proposal, insurance companies with excessively high claim denial rates will be subject to a thorough audit by the state. This audit will examine the reasons behind the denials, scrutinize the company’s claims processing procedures, and assess whether the denials are consistent with the terms of the insurance policies and established medical guidelines.
Corrective Action Plans: If an audit reveals that an insurance company is unjustifiably denying claims, the state will develop a corrective action plan for the insurer. This plan will outline specific steps the company must take to improve its claims processing practices, reduce its denial rate, and ensure that legitimate claims are being approved.
Enforcement Power: The state will have the authority to enforce these corrective action plans, ensuring that insurance companies are held accountable for implementing the necessary changes. This enforcement power will include the ability to impose penalties or take other disciplinary actions if an insurer fails to comply with the corrective action plan.
Impact on Consumers: This auditing process is designed to protect consumers from unfair claim denials, providing them with greater assurance that their insurance coverage will be honored when they need it most. It will also create a more level playing field between consumers and insurance companies, promoting greater transparency and accountability within the industry.

2. Creating a Public Intervenor Office for Consumer Advocacy:

To further empower consumers and provide them with the support they need to navigate the complexities of the healthcare system, Governor Evers proposes the creation of a new Public Intervenor Office. This office, a first of its kind in Wisconsin state history, will be dedicated to assisting individuals whose insurance claims have been denied.

Consumer Assistance: The Public Intervenor Office will provide a range of services to consumers, including helping them understand their rights under their insurance policies, guiding them through the appeals process, and providing legal assistance to pursue coverage for medical procedures, medications, and other healthcare services that have been unreasonably denied.
Investigating Fraudulent Acts: The office will also have the authority to investigate potential fraudulent acts by insurance companies, ensuring that they are operating in good faith and adhering to state regulations.
Leveling the Playing Field: By providing consumers with expert legal and advocacy support, the Public Intervenor Office will help level the playing field between individuals and insurance companies, ensuring that consumers have a strong voice in challenging unfair claim denials.

3. Reforming Prior Authorization Requirements:

Recognizing the significant burden that prior authorization requirements place on both patients and healthcare providers, Governor Evers’ plan includes a series of reforms aimed at streamlining the process, reducing delays, and ensuring that patients receive timely care.

Automatic Approval for High-Approval Procedures: Procedures and services that consistently receive high approval rates from insurance companies will be automatically approved, eliminating the need for unnecessary paperwork and delays. This will expedite access to care for common and well-established treatments.
Streamlining Approvals for Trusted Providers: Doctors who have a proven track record of receiving high approval rates from an insurer for specific procedures will be exempt from prior authorization requirements for those procedures. This will reduce administrative burdens on healthcare providers and allow them to focus on patient care.
Eliminating Prior Authorization for Inpatient Mental Health: In a critical step to address the mental health crisis, Governor Evers proposes eliminating prior authorization requirements for inpatient mental health services for both children and adults. This will ensure that individuals in crisis can access immediate, life-saving care without facing unnecessary delays or barriers.
Transparency in Covered Services: Insurance companies will be required to clearly list all covered services under each plan that require prior authorization, providing consumers with upfront information about potential delays and allowing them to make informed decisions when choosing a health plan.

4. Expanding Coverage and Establishing Network Adequacy Standards:

Governor Evers’ plan seeks to expand the scope of healthcare services that insurance companies are required to cover, ensuring that Wisconsinites have access to a comprehensive range of essential health benefits.

5. Addressing Surprise Medical Billing and Medical Debt:

Governor Evers’ plan includes measures to protect consumers from surprise medical bills and the harmful consequences of medical debt.

Curbing Surprise Billing: The plan will codify federal law to curb surprise billing for emergency services and expand upon those protections to include ground ambulance services and certain behavioral health services received during a crisis. This will help ensure that individuals are not burdened with unexpected and exorbitant medical bills for essential emergency care.
Notice of Unpaid Medical Bills: Healthcare providers will be required to give Wisconsinites notice of unpaid medical bills, providing them with an opportunity to address the debt before it is sent to collections.
Grace Period for Medical Debt: The plan will establish a six-month grace period, banning healthcare providers from reporting unpaid medical debt to consumer reporting agencies during that time. This will give individuals time to resolve the debt without negatively impacting their credit scores.

6. Expanding Telehealth Coverage:

Recognizing the growing importance of telehealth in providing access to care, particularly in rural areas, Governor Evers’ plan includes provisions to expand coverage and ensure parity for telehealth services.

Coverage for Telehealth Services: Insurance plans will be required to cover telehealth services if an equivalent in-person service is covered, expanding access to care for individuals who may have difficulty traveling to a healthcare facility.
Cost-Sharing Parity: Insurers will be prohibited from charging a higher cost-sharing amount for the telehealth version of an equivalent in-person service, ensuring that telehealth is a financially viable option for patients.
Eliminating Prior Authorization for Telehealth: Prior authorization requirements for telehealth services will be eliminated, streamlining access to virtual care.

7. Lowering Prescription Drug Costs and Combating Price Gouging:

Governor Evers’ “Less for Rx” plan, a key component of his budget proposal, aims to tackle the high cost of prescription drugs and protect consumers from price gouging.

Office of Prescription Drug Affordability: The plan establishes an Office of Prescription Drug Affordability to oversee prescription drug regulations, analyze drug policies, and develop strategies to reduce prescription drug costs for Wisconsinites.
Sales Tax Exemption for Over-the-Counter Medications: Over-the-counter medications will be exempt from sales tax, providing significant savings for consumers.
Insulin Copay Cap: A \$35 copay cap will be established for a month’s supply of insulin, making this life-saving medication more affordable for individuals with diabetes.
Insulin Safety Net Program: An Insulin Safety Net Program will be created to ensure that individuals with an urgent need for insulin, as well as those with lower incomes and limited insurance coverage, have access to affordable insulin.
Prescription Drug Affordability Review Board: A Prescription Drug Affordability Review Board will be established to oversee the pharmaceutical industry, analyze drug pricing practices, and set price ceilings on price-gouging prescription drugs.
Licensing and Regulation of Pharmacy Benefit Managers: Entities involved in the prescription drug supply chain, including pharmacy benefit managers, will be licensed and regulated to promote transparency and fair practices.
Importation of Prescription Drugs: A Prescription Drug Importation Program will be created to allow the state to import drugs that would create substantial savings for consumers and taxpayers.

8. Expanding BadgerCare:

As he has in previous budgets, Governor Evers is again proposing to expand BadgerCare, Wisconsin’s Medicaid program. This expansion would provide affordable healthcare coverage to over 95,000 low-income Wisconsinites, while also saving the state billions of dollars and drawing down additional federal funding.

Benefits of Medicaid Expansion: Studies have consistently shown that Medicaid expansion leads to improved access to care, better health outcomes, reduced mortality rates, and increased financial stability for both individuals and hospitals, particularly in rural areas.
Addressing Health Disparities: Medicaid expansion is a crucial step in addressing health disparities and ensuring that all Wisconsinites, regardless of their income, have access to the healthcare they need.

Conclusion: A Vision for a Healthier Wisconsin

Governor Evers’ comprehensive healthcare reform plan represents a bold and ambitious vision for a healthier Wisconsin. By tackling the systemic issues that have plagued the healthcare industry, holding insurance companies accountable, and prioritizing the needs of patients, this plan has the potential to transform the healthcare landscape in the state. It is a plan that recognizes healthcare as a fundamental right and seeks to ensure that all Wisconsinites have access to affordable, high-quality care, regardless of their circumstances. The implementation of these proposals would not only improve the health and well-being of countless individuals but also create a more just and equitable society for all.