Fee Schedule Related Topics

ACCREDITATION

What is the accreditation requirement?

Under the amended version of the No-Fault Act, certain providers are required to be accredited by the Commission on Accreditation of Rehabilitation Facilities (“CARF”) or the Joint Commission in order to be eligible for reimbursement for auto accident-related treatment rendered after July 1, 2021. See MCL 500.3157(12). Notably, so long as the provider is “in the process of becoming accredited” as of July 1, 2021, it will be eligible for reimbursement, “unless 3 years have passed since the beginning of that process” and the provider is “still not accredited.” Id.

To whom does it apply?

The new accreditation-for-reimbursement requirement applies only to a “neurological rehabilitation clinic” which the amended statute defines as “a person that provides post-acute brain and spinal rehabilitation care.” See MCL 500.3157(15)(g). For more information about which provider(s) qualify as a “neurological rehabilitation clinic” under the statutory definition, please refer to DIFS Bulletin 2020-27-INS or the relevant FAQs section on DIFS website, which is accessible here: DIFS’ FAQs on Accreditation.

CHARGE DESCRIPTION MASTER

What is a “charge description master”?

The amended version of the statute defines a “charge description master” as “a uniform schedule of charges represented by the person as its gross billed charge for a given service or item, regardless of payer type.” See MCL 500.3157(15)(a). If a provider had a “charge description master” in effect on January 1, 2019, the percentages identified in MCL 500.3157(7) will be applied to the amount payable for the treatment under that “charge description master” to determine the amount to which the provider is now eligible for reimbursement.

Does a provider have to produce its charge description master?

The amended version of the No-Fault Act itself is silent on this issue. However, in Bulletin 2021-36-INS, DIFS opined that an “insurer that receives [a bill for which reimbursement must be calculated under MCL 500.3157(7)] may request a charge description master” from a provider “in order to calculate the amount of the provider’s reimbursement.” In addition, the Bulletin states that “[t]he insurer must reimburse the provider promptly upon receipt of the required documentation,” which suggests that producing a “charge description master” (when requested) may be a requirement, at least in DIFS’ opinion. Further, under the No-Fault Fee Schedule Rules, a provider “shall submit” its charge description master to DIFS, if it elects to appeal an insurer’s initial determination of its claim(s) under the new utilization review process. See R. 500.205(1)(a). For more information about the utilization review process, please click here: ANFL Utilization Review.

What if a provider had no charge description master on January 1, 2019?

If a provider did not have a charge description master in effect on January 1, 2019, it is appropriate for a no-fault insurer to consider the “average amount” the person charged on that date in calculating reimbursement under the amended version of the statute. Specifically, if a provider had no charge description master as of January 1, 2019, then the percentages identified in MCL 500.3157(7) will be applied to the “average amount the person charged for the treatment on January 1, 2019” to determine the amount to which the provider is now eligible for reimbursement.

What if a provider was not in business on January 1, 2019?

The amended version of the No-Fault Act does not expressly address this issue. Under the statute, an argument can be made that providers that did not exist as of January 1, 2019 – and, thus, did not have a “charge description master” in effect or an “average amount” being charged for treatment on that date – are subject only to the “reasonable” and “customary” charge requirements set forth in MCL 500.3157(1) and not to any reimbursement limitations set forth in MCL 500.3157(7). However, under the No-Fault Fee Schedule Rules, which became effective as of October 1, 2021, DIFS “shall consult the FAIR Health benchmarking database to determine the average amount charged in the applicable geozip for the service or services at issue” in cases in which a provider has submitted an appeal to DIFS under the new utilization review process but had no charge description master and no average amount charged for the subject treatment as of January 1, 2019. See R. 500.205(1)(c).

Can a provider obtain copies of other providers’ charge description masters?

Yes, DIFS has created a publicly accessible website where hospital and non-hospital providers can voluntarily post their charge description masters The non-hospital providers’ charge description masters are available here: Non-Hospital Charge Description Masters. The hospital charge description masters are available here: Hospital Charge Description Masters.

CPI ADJUSTMENT

What adjustment(s), if any, apply to the “fee schedule”?

Under the amended version of the No-Fault, an amount payable under the “fee schedule” for non-Medicare reimbursable treatment must be adjusted annually based on changes to the Consumer Price Index (“CPI”) for the previous year. Specifically, MCL 500.3157(9) provides:

“An amount that is to be applied under subsection (7) or (8), that was in effect on January 1, 2019, including any prior adjustments to the amount made under this subsection, must be adjusted annually by the percentage change in the medical care component of the Consumer Price Index for the year preceding the adjustment.”

What is the current CPI adjustment?

The current CPI adjustment is set forth in DIFS Bulletin 2022-04-INS, which is accessible here: DIFS Bulletin 2022-04-INS. Specifically, that Bulletin provides that “any amount payable that were [sic] in effect on January 1, 2019 for the purposes of MCL 500.3157(7) or MCL 500.3157(8) shall be increased by 5.39% for dates of service July 2, 2021 through July 1, 2022.” Notably, this Bulletin supersedes and replaces DIFS Bulletin 2021-16-INS, which previously provided for an increase of 4.11% and which is accessible here: DIFS Bulletin 2022-04-INS.

ENHANCED REIMBURSEMENT

Who is eligible for enhanced reimbursement under MCL 500.3157?

There are four special types of providers that are eligible for enhanced reimbursement under MCL 500.3157:

(1) Tier 1 Medicaid provider, which is defined as a physician, hospital, clinic or other person who has “20% or more, but less than 30%, indigent volume determined pursuant to the methodology used by the department of health and human services in determining inpatient medical/surgical factors used in measuring eligibility for Medicaid disproportionate share payments” as of July 1 of the year in which treatment is rendered. See MCL 500.3157(4)(a).

(2) Tier 2 Medicaid provider, which is defined as “[a] physician, hospital, clinic, or other person that provides 30% or more of its total treatment or training” to an indigent patient population as “determined pursuant to the methodology used by the department of health and human services in determining inpatient medical/surgical factors used in measuring eligibility for Medicaid disproportionate share payments” as of July 1 of the year in which treatment is rendered. See MCL 500.3157(4)(a); MCL 500.3157(5).

(3) Designated freestanding rehabilitation facility, which is defined as “an acute care hospital to which all of the following apply:

(i) The hospital has staff with specialized and demonstrated rehabilitation medicine expertise.

(ii) The hospital possesses sophisticated technology and specialized facilities.

(iii) The hospital participates in rehabilitation research and clinical education.

(iv) The hospital assists patients to achieve excellent rehabilitation outcomes.

(v) The hospital coordinates necessary post-discharge services.

(vi) The hospital is accredited by 1 or more third-party, independent organizations focused on quality.

(vii) The hospital serves the rehabilitation needs of catastrophically injured patients in this state.

(viii) The hospital was in existence on May 1, 2019.” [MCL 500.3157(4)(b)]

(4) Level I or Level II trauma center, which is defined as “a hospital that is a level I or level II trauma center” which renders “treatment for an emergency medical condition” and “before the patient is stabilized and transferred.” See MCL 500.3157(6).

How can a provider qualify as a Tier I or Tier 2 Medicaid provider?

To qualify for enhanced reimbursement as a Tier I or Tier 2 Medicaid provider, the provider “shall provide the [DIFS] director with all documents and information requested by the director” and the director “shall annually review the documents and information provided” and “certify the person as qualifying.” See MCL 500.3157(5). Under the amended statute, the director is required to provide a list of providers who qualify as Tier I or Tier 2 Medicaid providers for purposes of enhanced reimbursement. A copy of the current list can be accessed here: Link to List of Certified Tier I and Tier 2 Medicaid Providers.

How can a provider qualify as a Level I or II trauma center?

To qualify for enhanced reimbursement as a Level I or Level II trauma center, a provider must be verified as a Level I or Level II trauma center by the American College of Surgeons Committee on Trauma. DIFS has produced a list of Level I or II trauma centers which are entitled to enhanced reimbursement, which can be accessed here: Link to List of Level I or II Trauma Centers Entitled to Enhanced Auto Insurance Reimbursement.

What providers qualify as freestanding rehabilitation facilities?

To qualify for enhanced reimbursement as a freestanding rehabilitation facility, the DIFS director must designate a provider as such. Under the amended version of the No-Fault Act, DIFS will only designate 2 providers as freestanding rehabilitation facilities eligible

for enhanced reimbursement for a particular year. See MCL 500.3157(4)(b). In Bulletin 2021-24-INS, which is accessible here: Bulletin 2021-24-INS, the DIFS director designated Mary Free Bed Rehabilitation Hospital and DMC Rehabilitation Institute of Michigan as the only 2 freestanding rehabilitation facilities eligible for enhanced reimbursement.

FAIR HEALTH DATA

Can FAIR Health data be used to calculate reimbursement owed to a provider?

The amended version of the No-Fault Act does not directly address this issue. However, under the No-Fault Fee Schedule Rules, DIFS “shall consult the FAIR Health benchmarking database to determine the average amount charged in the applicable geozip for the service or services at issue based on FAIR Health’s most recently published data that includes dates of service on January 1, 2019” in cases in which a provider has submitted an appeal to DIFS under the new utilization review process but had no charge description master and no average amount charged for the subject treatment as of January 1, 2019. See R. 500.205(1)(c). Notably, DIFS has stated that it will not use FAIR Health data for existing providers that have a charge description master or can provide an average amount charged as of January 1, 2019 to support their appeal.

How can a provider access FAIR Health data?

According to DIFS, FAIR Health will purportedly give providers access to its data for an administrative fee. To inquire about obtaining a license or access to FAIR Health’s “benchmarking file,” a provider can call 855-301-3247 or e-mail service@fairhealth.org.

THE USE OF CLAIM FORMS AND CODES

Must a provider submit claims on a particular form?

Nothing in the Insurance Code, the No-Fault Act or in any appellate authority interpreting those statutes requires a provider to use a particular billing format or claim form to obtain reimbursement for auto accident-related treatment. All that the No-Fault Act requires a provider to submit is “reasonable proof of the fact and amount of loss sustained,” which Michigan appellate courts have generally interpreted as being satisfied by submitting bills and medical records for the treatment at issue. See MCL 500.3142.

In Bulletin 2021-36-INS, a copy of which can be accessed here: Bulletin 2021-36-INS, DIFS reaffirmed these principles and noted that Michigan’s “Insurance Code does not mandate that a provider use a particular form to be entitled to reimbursement, and a provider’s failure to use the insurer’s preferred billing format is not, itself, failure to provide ‘reasonable proof of loss.’”

Further, DIFS opined that “[w]hile some insurers may have a preferred billing form (e.g., the CMS-1500 or CMS-1450/UB-04), a provider who uses a different form or an invoice to submit a bill that is otherwise payable is nonetheless entitled to timely payment.”

Must a provider bill using codes?

Nothing in the Insurance Code, the No-Fault Act or in any appellate authority interpreting those statutes requires a provider to bill using any procedure or other code(s) to obtain reimbursement for auto accident-related treatment. As noted above, all that the No-Fault Act requires a provider to submit is “reasonable proof of the fact and amount of loss sustained,” which Michigan appellate courts have generally interpreted as being satisfied by submitting bills and medical records for the treatment at issue. See MCL 500.3142.

In Bulletin 2021-35-INS, a copy of which can be accessed here: Bulletin 2021-35-INS, DIFS suggested that providers should include appropriate codes on bills for treatment that is payable under Medicare. Specifically, DIFS opined that “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.” However, this guidance is expressly limited to bills for treatment that is payable under Medicare. No such guidance or direction exists for treatment that is not payable under Medicare.