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longer in duration or more frequent than, or extend over a greater number of days than what is usually required for the injured person’s diagnosis or condition, the Final Rules would permit an insurer or the MCCA to request that the provider submit a written explanation to the insurer or MCCA regarding the necessity or indication for the treatment, training, products, services, or accommo- dations provided. The insurer or MCCA may also request that the provider include in is written explanation medical records, bills, and other information concerning the treatment, training, products, services or accommo- dation. However, if the insurer/MCCA requests medical records, bills or other information in excess of the information that customarily accompanies a bill submit- ted to the insurer/MCCA, the Final Rules would require the insurer/MCCA to reimburse the provider at a reason- able and customary fee to provide the additional information, including the actual costs of copying and mailing. A request for a written explanation must be submitted to a provider within 30 days of the insurer/ MCCA’s receipt of the bill related to the treatment, training, products, services or accommodations at issue. Likewise, a provider who receives a request for a written explanation must respond within 30 days of receipt of the insurer/MCCA’s request.
Insurer Determinations and Provider Appeals Process
If an insurer or the MCCA receives a provider’s written explanation as discussed above and determines that a provider overutilized or otherwise rendered or ordered inappropriate treatment, training, products, services or accommodations, or that the cost was inappropriate, the Final Rules would require an insurer or the MCCA to issue a written notice of its determination to the provider within 30 days of receipt of the provider’s written explanation. The notice must include all of the following information:
• Thecriteriaorstandardsonwhichtheinsurer/MCCA relied in making its determination, with specific reference to the insurer’s utilization review program.
• Theamountofpaymenttotheproviderthathas been made as a result of the determination, includ- ing an explanation for the difference between that amount and the amount billed by the provider.
• Ifapplicable,adescriptionofanyadditionalrecords the provider must submit to the insurer/MCCA in order for the insurer/MCCA to reconsider its determination.
• Acopyofanappealformtobeprescribedbythe Department.
• Thedateofthedetermination.
• IfaninsurerortheMCCAdeniesaprovider’sbillin whole or in part on the basis that the provider
overutilized or otherwise rendered or ordered inappropriate treatment, training, products, ser- vices or accommodations, or that the cost was inappropriate, the Final Rules would permit a provider to appeal the determination to the Depart- ment within 90 days of the date of the disputed determination. A provider may appeal the insurer/ MCCA’s determination whether or not the insurer/ MCCA requested a written explanation. An appeal to the Department must be submitted on a form prescribed by the Department.
Within 14 days of receipt of a provider’s appeal, the Department must notify the insurer/MCCA and the injured person of the appeal and request any additional information necessary to review the appeal. The Final Rules require an insurer/MCCA to file a reply to the appeal within 21 days after the date of the Department’s notice of appeal. The Department must issue a decision within 28 days after the insurer/MCCA files a reply to the provider appeal, or if the insurer/MCCA fails to submit a reply, within 28 days after the time for filing a reply has expired. The Department hay taken an additional 28 days to issue a decision upon written notice to the insurer/MCCA and the provider.
If the provider’s appeal is successful, the provider is entitled to recover interest on any overdue payments under the No-Fault Act, which is presently 12% annually. However, the Department’s decision is subject to judicial review by a Circuit Court as provided in the Administra- tive Procedures Act.
The Final Rules leave unclear whether a provider’s appeal to the Department of an insurer’s denial of a bill on the basis of overutilization or inappropriate cost is an exclusive remedy, or if the provider may alternatively file a lawsuit against the insurer/MCCA for overdue benefits as reinstated by the Auto No-Fault Reform legislation under MCL §500.3112. Unless the Michigan legislature amends the Auto No-Fault Act to provide clarity on the issue, a provider’s available remedies to dispute an insurer/MCCA’s adverse determination will be determined by judicial review by Michigan appellate courts.
Insurer Utilization Review Programs
Within 60 days of the effective date of the Final Rules, insurers will be required to have in place a utilization review program to review records and bills for treat- ment, training, products, services, and accommodations provided to an injured person that is above the usual range of utilization based on medically accepted standards. An insurer’s utilization review program must do all of the following:
• Provideforbillreview,includingwhetherprovider charges for treatment, training, products, services, andaccommodationscomplywiththeAutoNo-Fault Act and rules promulgated thereunder.
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