WI SB1097

Creates the Office of the Public Intervenor attached to the Office of the Commissioner of Insurance to assist individuals with health insurance claims, appeals, and legal actions for medical coverage; funded through assessments on insurers based on health insurance premium volume

Requires insurers to process health insurance claims within reasonable timeframes, provide detailed explanations for denials citing specific medical or policy bases, and disclose when artificial intelligence or algorithmic decision-making is used in claims processing

Prohibits insurers from using vague terms to deny claims, allowing non-physicians to determine medical necessity, mandating prior approval that causes harmful delays, requiring patients to fail cheaper treatments first (step therapy), and applying stricter standards to mental health claims than physical health claims

Mandates annual public reporting beginning January 1, 2027 on claim denial rates, reasons for denials, appeal outcomes, and AI usage statistics; commissioner must maintain a public database of denial rates and independent review outcomes

Authorizes the insurance commissioner to audit insurers with excessive claim denial frequencies, order corrective action plans, and impose $10,000 civil forfeitures per occurrence for violations causing harmful care delays or adverse health outcomes