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Utilization Review and Fee Schedule

Utilization Review and Fee Schedule

  1. When will more information be available about the fee schedule?

    The statutorily required fee schedule will take effect July 2, 2021. DIFS released draft rules related to the fee schedule on May 17, 2021.

    For more information about the rulemaking process, visit the Michigan Office of Administrative Hearings and Rules website.

  2. Will the fee schedule apply to existing claims?

    Yes. When the fee schedule becomes effective after July 1, 2021, it will apply to new and existing claims for treatment rendered after July 1, 2021.
  3. The Act allows for the development and use of managed care networks. With respect to that:
     
    1. Does DIFS have an expectation relative to the amount of discount?

      An insurer will be required to demonstrate that the discount is appropriate for the coverage provided.
    2. Would the new fee schedule and utilization language also apply?

      Yes, the fee schedule (Section 3157) and utilization review (Section 3157a) will apply to managed care networks.
  4. Under the proposed rules, when would DIFS use FAIR Health data?

    Under the proposed rules, DIFS will use FAIR Health data in the course of a provider appeal under the Utilization Review program if the provider does not have a charge description master in effect on January 1, 2019 and also cannot provide an average amount charged for the service at issue as of January 1, 2019.
  5. I am a provider that has a charge description master or can provide an average amount that I charged for a service as of January 1, 2019. Will DIFS use FAIR Health data to determine the reimbursement amount I am entitled to?

    No. During a provider appeal under the Utilization Review program, DIFS will use FAIR Health data if a provider does not have a charge description master in effect on January 1, 2019 and also cannot provide an average amount charged for the service at issue as of January 1, 2019. Existing providers that have a charge description master or that can provide an average amount will rely on those documents to support their appeal and FAIR Health data will not be used.
  6. Which FAIR Health product does DIFS propose to use?

    DIFS will use FAIR Health's charge benchmark suite of modules. The specific module will depend on which health care service is at issue and which type of provider is filing an appeal.
  7. If a procedure code is listed in two different FAIR Health benchmarks, which charge will DIFS use?

    Certain codes may be billed by both professional providers and health care facilities using different medical billing forms. FAIR Health maintains data billed by such providers and facilities separately, resulting in different benchmarks. The benchmark used will depend on the type of provider.
  8. Will DIFS post FAIR Health data?

    No. However, FAIR Health will give providers access to its data for a small administrative fee.
  9. I have a question about what type of code or modifier to use. Can DIFS answer my question?

    No. DIFS cannot provide guidance on billing and coding questions, including whether to include a modifier or which type of code to use.
  10. Does DIFS require providers to bill claims using a specific form, such as the CMS-1500?

    No. However, auto insurers may have specific requirements and providers should contact them directly.
  11. Do health care providers need to be Medicare-certified to be eligible for reimbursement for no-fault claims?

    No. Under MCL 500.3157(1), a provider must "lawfully render treatment" in order to be reimbursed.
  12. Under the proposed rules, which Medicare fee schedule should be used?

    Under the proposed rules, the fee schedule is "the Medicare fee schedule or prospective payment system in effect on March 1 of the service year in which the services are rendered and for the area in which such services are rendered." "Service year" means the period from July 2 through July 1 of the following year. For example, for services rendered between July 2, 2021 and July 1, 2022, the applicable fee schedule would be the one in effect as of March 1, 2021.
  13. Will DIFS publish providers' charge description masters?

    As a convenience, DIFS is developing a website where hospitals can voluntarily post their charge description masters so that insurers have ready access to them. DIFS will not collect or publish non-hospital charge description masters. A link to the website will be provided when the project is complete.
  14. Which providers are entitled to payments based on indigent volume under MCL 500.3157(4)(a) and MCL 500.3157(5)?

    Under the fee schedule, a provider that has over 20% indigent volume is entitled to increased reimbursements. "Indigent volume" is 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." The methodology employed by DHHS applies only to hospitals; there is no methodology applicable to non-hospital providers. Accordingly, only hospitals that are eligible for Medicaid disproportionate share payments, and thus who have "indigent volume," will qualify for increased reimbursement under MCL 500.3157(4) and (5).

  15. Where can providers learn more about medical billing or coding?

    The Medicare Learning Network (MLN) provides free educational materials for health care professionals on CMS programs, policies, and initiatives including trainings, events, and other resources on a variety of medical billing and coding topics.

  16. What types of services are eligible for enhanced reimbursement for a hospital that is a level I or level II trauma center?

    MCL 500.3157(6) states that the enhanced reimbursement applies to "a hospital that is a level I or level II trauma center that renders treatment to an injured person for an accidental bodily injury covered by personal protection insurance, if the treatment is for an emergency medical condition and rendered before the patient is stabilized and transferred." If the treatment is not for an emergency medical condition and rendered before a patient is stabilized and transferred, then the hospital is not eligible for enhanced reimbursement.