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Fee Schedule Frequently Asked Questions

OTHER FAQS– AND ANSWERS

Do the reimbursement limitations set forth in MCL 500.3157 apply to any and all types of products, services or accommodations rendered?

No, or at least not according to DIFS. Specifically, in Bulletin 2021-38-INS, DIFS opined that “[p]roducts, services, and accommodations that are not provided by physicians, hospitals, clinics, or other like persons, but which are otherwise compensable as ‘allowable expenses’ under PIP, are not subject to” the reimbursement limitations set forth in MCL 500.3157 but are “instead subject to MCL 500.3107(1)(a), which requires [only] that these charges be ‘reasonable.’” Bulletin 2021-38-INS. Further, in the Bulletin, DIFS provided the following non-exhaustive list of examples of treatment that is subject only to the “reasonableness” requirement of MCL 500.3107(1)(a) and not to the reimbursement limitations of MCL 500.3157:

  • Services related to guardianship or conservatorship;
  • Vehicle modifications;
  • Home modifications;
  • Computer equipment and supplies;
  • Generators;
  • Non-emergency medical transportation;
  • Non-prescription drugs and over-the-counter medical supplies; and
  • Certain case management services

To obtain payment up to 200% of the Medicare rate under MCL 500.3157(2), must a provider satisfy Medicare criteria or conditions for reimbursement?

Most likely no. While MCL 500.3157(2) provides that “a physician, hospital, clinic, or other person that renders” auto accident-related treatment “is not eligible for payment or reimbursement” for more than “200% of the amount payable to the person for the treatment or training under Medicare,” MCL 500.3157(15)(f) defines Medicare as “fee for service payments” under “the federal Medicare program . . . without regard to the limitations unrelated to the rates in the fee schedule.” Accordingly, a compelling argument can be made that a provider need not satisfy any particular criteria or conditions for reimbursement under the federal Medicare program in order to be eligible for reimbursement up to 200% of the Medicare rate under MCL 500.3157(2).

If the applicable multiplier of the Medicare rate for a particular type of treatment is more than what I was charging on January 1, 2019 for that treatment, will I actually fare better under the new “fee schedule”?

No. The amended version of the No-Fault Act caps reimbursement at the lesser of (a) the amount that would be payable by multiplying the applicable percentage to the Medicare rate for the treatment at issue; or (b) the average amount the provider charged for that treatment as of January 1, 2019. Specifically, MCL 500.3157(8) provides:

“For any change to an amount payable under Medicare as provided in subsection (2), (3), (5), or (6) that occurs after the effective date of the amendatory act that added this subsection, the change must be applied to the amount allowed for payment or reimbursement under that subsection. However, an amount allowed for payment or reimbursement under subsection (2), (3), (5), or (6) must not exceed the average amount charged by the physician, hospital, clinic, or other person for the treatment or training on January 1, 2019.”

In other words, the highest amount to which a provider can be eligible for payment for Medicare-reimbursable treatment under MCL 500.3157(2), (3), (5), or (6) is the average amount that provider charged for the treatment as of January 1, 2019. Accordingly, a provider of Medicare reimbursable treatment will not fare better under the new “fee schedule” that it did before the schedule was implemented.

What are the avenues for a provider to challenge an insurer’s denial or failure to make full (or expected) reimbursement of a provider’s charge?

There are two avenues available for a provider to challenge an insurer’s initial determination of its charges and/or an insurer’s failure to make appropriate, expected or prompt payments of its charges: (1) filing a lawsuit in a trial court; and (2) filing an administrative appeal with DIFS under its new utilization review process.

With regard to the first option (i.e., filing a lawsuit), providers should bear in mind that a lawsuit must, generally, be filed against the appropriate no-fault insurer within one year of the date that the unpaid expense was incurred in order to protect and preserve the provider’s right to recover that expense. See MCL 500.3145. The right to file and pursue such a lawsuit was conferred upon and guaranteed to providers in the amended version of MCL 500.3112, which became effective on June 11, 2019.

With regard to the second option (i.e., filing a DIFS appeal), providers should be aware that, under the Utilization Review Rules, an appeal must be filed with DIFS within 90 days of the insurer’s determination of the charge(s) at issue in order to protect and preserve the provider’s right to avail itself of the administrative appeal process. For more information about the Utilization Review Rules and/or DIFS’ new utilization review process for provider appeals, please visit https://autonofaultlaw.com/michigan-no-fault-utilization-review/.

If you have any fee schedule-related questions for the ANFL Editorial Board, please submit them to autonofaultlaw@sinasdramis.com.

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