Court of Appeals Rules for Providers in ANF Case

The Michigan Court of Appeals ruled 2-1 in favor of providers to declare that statutorily set reimbursement rates for auto accident no-fault claims could not be applied retroactively. The new reimbursements went into effect in July, 2021.

The 2-1 ruling, in Ellen M. Andary, Philip Krueger, & Eisenhower Center, v. USAA Casualty Insurance Company and Citizens Insurance Company of America, called upon the fact that legislative intent did not make it clear that the new rates were intended to be retroactive for cases that had arisen previous to the rates that went into effect, and even if it had, the legislature would be unable to make such a law due to impairments of constitutional contract provisions.

While the case is a victory for providers, especially those caring for auto accident victims from prior to 2019, it is highly likely that the case will be appealed for a final decision at some point before the Michigan Supreme Court. There is not an automatic right to appeal for the defendants, but the Michigan Supreme Court could grant leave to appeal. Under the Court of Appeals ruling, payments to providers for patients with injuries incurred before the effective date of the law return to charges 21 days after this ruling unless there is further court action. The MHA will provide an analysis to members of the policy impact of this decision and will keep members apprised of the legal status of challenges to the amended auto no fault law.

Those with questions may contact Laura Appel at the MHA.

DIFS Utilization Review Decisions Favor Hospitals

The Michigan Department of Insurance and Financial Services (DIFS) issued in early April two important utilization review decisions in favor of hospitals related to auto no-fault insurance reimbursement. Under the new system enacted as part of Public Act (PA) 21 of 2019, hospitals are entitled to more than Medicare reimbursement when the cost of treatment is covered by the auto no-fault insurance system. PA 19 does not adequately define Medicare rates and some auto no-fault insurers have paid less than appropriate amounts for hospital services rendered to auto accident patients. These decisions are extremely helpful in establishing the appropriate methodology to use in determining auto no-fault insurance reimbursement moving forward.

In the case of Hurley Medical Center v. Pioneer State Mutual Insurance Company, DIFS Director Anita Fox found that Medicare “pass-through” payments for graduate medical education, nursing and allied health, and the ancillary adjustment are payable under section 500.3157 of the Michigan Insurance Code. These amounts are payable in addition to the appropriate base payment rate multiplied by the diagnosis related group (DRG) relative weight. The ultimate amount in dispute in this case is $3,500, which the insurer now owes to Hurley Medical Center.

The case of Hurley Medical Center v. Progressive Michigan Insurance Company involved a dispute over the appropriate DRG. Progressive Michigan disputed the DRG, which totaled $58,126 after the amount was multiplied pursuant to PA 19. In response to the bill from Hurley, Progressive paid a DRG-multiplied amount of $26,642. After review, Fox found that Hurley Medical Center billed under the appropriate DRG, more than doubling the amount owed to the hospital. The amount payable to Hurley was reduced by $200 because the multiplied DRG amount exceeded Hurley’s charge for the service by that amount.

In each case, the insurer may appeal the finding to the circuit court. The MHA is tracking further developments in these cases, as well as several other utilization review appeals pending before DIFS. The MHA is also preparing a Utilization Review Appeals Toolkit to guide members through the utilization review (UR) process including the deadlines for filing UR appeals, specific information required for filings, a pre-filing checklist and a sample cover letter for filings. That information is expected to be sent to members by the end of April. For more information about these decisions and other auto no-fault insurance reimbursement issues, contact Laura Appel at the MHA.