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preceding the adjustment. Enhanced caps are avail- able to eligible physicians, hospitals, clinics and other providers with specified volumes of indigent care, or which are designated free standing rehabili- tation facilities, or which are level I or II trauma center hospitals furnishing emergency care to indi- viduals injured in auto accidents, if approved by the Michigan Department of Insurance and Financial Services (the “Department”).
Even if a physician or other provider charges
an amount which does not exceed the fee cap, insurers are still permitted to challenge whether the fee is reasonable. In other words, charging the amount permitted by the fee cap does not entitle the provider to the presumption that the fee is reasonable.
Recent Bulletins Addressing Delays in Payment of Reimbursement
Since September 2021, the Department has issued several Bulletins addressing delays in the payment of reimbursement which physicians and other health care providers have experienced from no-fault insurers since the reform legislation took effect.
Bulletin 2021-35-INS
Bulletin 2021-35-INS, issued on September 22, 2021, states the Department’s expectations for providers and insurers to ensure the timely and appropriate payment of benefits.
Under MCL §500.3142, personal injury protection (PIP) benefits are overdue if not paid within 30 days after an insurer receives reasonable proof of the fact and of the amount of loss sustained. If a bill is not provided to an insurer within 90 days after the product, service, accommodations, or training is provided, the insurer has 90 days to pay before the benefits are overdue. MCL §500.3142(3). Overdue payments bear simple interest at the rate of 12%
per annum. MCL §500.3142(4).
Bulletin 2021-35-INS states that in the case of treatment or training payable under MCL §500.3157,
if a provider has submitted a bill to an insurer but has not correctly coded a particular product, service, or accommodation that is payable under Medicare, the provider may need to re-submit the bill to the insurer with the appropriate code. The Bulletin states that as insurers and providers adjust to the new law, insurers are expected to engage in a dialogue with providers to assist them in understanding the insur- er’s review of the provider’s bills and to expedite bills resubmitted with corrected codes.
DECEMBER 2021/JANUARY 2022 | WWW.OCMS-MI.ORG
Bulletin 2021-35-INS advises insurers that the Department will carefully scrutinize complaints in which an insurer has repeatedly rejected a provider’s bills without offering assistance. The Department expects providers and insurers to attempt to resolve billing and coding disputes informally, as they have customarily done prior to the implementation of the fee schedule. In addition, the Bulletin states that the Department expects insurers to provide reasonable assistance to ensure that the insurer’s billing and coding requirements are clearly conveyed to provid- ers and their billers. If an insurer has issued a deter- mination or denied a bill on the basis that the provid- er rendered inappropriate products, services, or accommodations, or that the cost was inappropriate under the Insurance Code, the provider is entitled to file a provider appeal with the Department’s Utiliza- tion Review program. Providers are advised, howev- er, that under the Insurance Code, the Utilization Review process is available only to resolve questions of medical necessity or appropriateness of cost. The Department’s Utilization Review program cannot
be used to resolve billing or coding disputes that occur prior to a formal determination issued by the insurer as to the medical necessity or appropriate- ness of cost.
Bulletin 2021-35-INS encourages providers to review the Department’s Health Care Provider’s Guide to Michigan’s Auto Insurance Utilization Review Process before filing an appeal.
Bulletin 2021-36-INS
In Bulletin 2021-36-INS issued on October 5, 2021, the Department reminds insurers that payments are due to providers upon receipt of reasonable proof of loss. This Bulletin addresses three common situations: (1) the provider has not used the insurer’s preferred billing format; (2) the insurer disputes whether the provider has submitted adequate documentation for the insurer to calculate the appropriate reimbursement under MCL §500.3157(7); and (3) the insurer and provider disagree that the claims have been billed using the appropriate code.
With respect to billing format disputes, Bulletin 2021-36-INS acknowledges the Department’s aware- ness that some insurers have been refusing to pay provider bills on the basis that the bill is not in the insurer’s preferred format or on the insurer’s preferred form. The Department states that the Insurance Code does not mandate that a provider use a particular form to be entitled to reimburse- ment, and a provider’s failure to use the insurer’s preferred billing format is not per se failure to provide “reasonable proof of loss.” While some
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