Surprise Medical Billing Information for Providers, Carriers
Michigan’s surprise medical billing law, MCL 333.24501 to MCL 333.24517 of the Public Health Code, requires the Michigan Department of Insurance and Financial Services (DIFS) to administer certain aspects of the law. These responsibilities include reviewing a carrier’s calculation of its negotiated median amount upon a nonparticipating provider’s request (MCL 333.24510), facilitating arbitration (MCL 333.24511), and preparing an annual report (MCL 333.24515).
Pursuant to MCL 333.24517, DIFS is promulgating rules that provide procedures for calculation reviews conducted by DIFS and for the approval of arbitrators. The draft rules remain pending in the rule promulgation process. Current information regarding the status of the draft rules may be obtained by visiting the Michigan Office of Administrative Hearings and Rules website for pending rule sets.
Provider Requests for Calculation Reviews
Beginning July 1, 2021, if a nonparticipating provider believes that a carrier incorrectly calculated its negotiated median amount when providing payment to the provider pursuant to MCL 333.24507(2)(a) or MCL 333.24509(5)(a), the provider may submit a request to DIFS for a review of the calculation.
Nonparticipating providers must submit the request for a calculation review by completing the Request for Review of Calculation of Charges form (FIS 2369). The form must be submitted to DIFS by email to DIFS-SurpriseBilling@michigan.gov or by fax to 517-763-0305.
Note: Under MCL 333.24510(3), a nonparticipating provider shall not file a subsequent request for a review if the request involves the same rate calculation for a health care service for which the provider has previously received a determination from DIFS under MCL 333.24510.
Following the submission of a request for a calculation review, DIFS will notify the carrier within 14 days and may request information DIFS believes is necessary to assist in reviewing the calculation described above. Within 14 days after the carrier’s timely and complete response, or after the expiration of the period of time within which the carrier was required to respond, DIFS will issue its determination.
Provider Requests for Binding Arbitration
Under MCL 333.24511, a nonparticipating provider may file a claim with the carrier for an additional payment for health care services provided to certain emergency patients involving a complicating factor, as defined under the statute. The statute governs what documentation the provider must submit to the carrier and states that the carrier must respond within 30 days by denying the claim or making the additional payment, as calculated under the statute.
Beginning July 1, 2021, if a carrier denies a nonparticipating provider’s claim, the provider may submit a written request to DIFS for binding arbitration. Providers must submit the request for binding arbitration by completing the Request for Binding Arbitration form (FIS 2368). The form must be submitted to DIFS by email to DIFS-SurpriseBilling@michigan.gov or by fax to 517-763-0305.
Note: Failure to include the documentation required in the Request for Binding Arbitration form (FIS 2368) may result in a denial of the request for binding arbitration.
DIFS will notify the carrier following the acceptance of a request for binding arbitration. Under MCL 333.24511(4), within 30 days after receiving notice from DIFS, the carrier shall submit written documentation to DIFS confirming the denial or providing an alternative payment offer to be considered in arbitration.
Under MCL 333.24511(5), the parties must agree on an arbitrator from the DIFS Approved Arbitrator List. Providers and carriers are strongly encouraged to ensure they are consulting the list of approved arbitrators published when the arbitration process is commenced, as the list will be updated annually and may be updated more frequently, as necessary.
Approval of Arbitrators
DIFS is responsible for creating and maintaining a list of arbitrators who are approved by DIFS and trained by the American Arbitration Association or American Health Law Association.
Arbitrators who would like to apply for approval and inclusion on the Approved Arbitrators List must complete the Surprise Medical Billing Arbitrator form (FIS 2366). The form must be submitted to DIFS by email to DIFS-SurpriseBilling@michigan.gov or by fax to 517-763-0305.This must be submitted no later than 60 days before the arbitrator would like to begin providing arbitration services. Failure to include the documentation required in the form may result in a denial of the application. Applicants who have been denied may reapply at any time.
Approved arbitrators who are currently included on the Approved Arbitrators List must complete the Surprise Medical Billing Arbitrator form (FIS 2366) to do any of the following:
- Make an annual attestation that the information provided to DIFS remains complete and accurate. Please consult your approval letter to determine your renewal date.
- Inform DIFS of a change in the arbitrator’s information. The form must be submitted within 30 days of the change.
- Request removal from the Approved Arbitrators List.
Approved arbitrators must submit the form to DIFS by email to DIFS-SurpriseBilling@michigan.gov or by fax to 517-763-0305.
Under MCL 333.24515, DIFS is required to prepare and post online an annual report that includes certain information regarding complaints received and the number of requests made for calculation reviews and binding arbitration. The report will be posted here when it is available.
For carriers and providers:
Phone: 833-ASK-DIFS (833-275-3437)