State Representative Julie Rogers has introduced a bill to modify the system for medical care providers to appeal denials of payment for their treatment of severely injured car crash survivors under Michigan's 2019 auto no-fault law.
The system, called "utilization review," dictates how medical care providers can make their appeals.
Medical care providers don't want to get rid of utilization review, because it can cut down on the need to file lawsuits in order to get paid. But they say the current system is biased in favor of insurance companies.
The bill is the first of several expected this year to address serious problems with the 2019 auto no-fault law.
“The care crisis facing Michigan automobile crash survivors worsens every day and we must begin to address the consequences of the 2019 auto no fault law now,” said Rogers.
The current utilization review system is being used by insurance companies as "just another tool in the toolbox for denying care," according to Tim Hoste, head of the Coalition Protecting Auto No Fault. He said the appeals process can take months, and during that time, the provider doesn't get paid.
Hoste said the current no-fault law permits insurance companies to refer to "medically accepted guidelines," when determining if services are appropriate.
"The problem is, when those guidelines are developed by private, for-profit corporations, it puts the decision in the hands of someone who has never treated the person, and a lot of times has done nothing more than review a file," said Hoste.
HB 4884 substitutes "generally accepted standards," for "medically accepted standards," and prohibits using for-profit corporations to set the standards.
Hoste said insurance companies will be less likely to deny payment for care, if they know the utilization review process will rely on evidence-based standards relied on by medical professionals, for example.
The Michigan insurance industry opposes any change to the 2019 no-fault law.
"We know utilization review has been working with the standard of medically necessary care," said Erin McDonough, head of the Insurance Alliance of Michigan.
She said the current system limits medically unnecessary care.
"Overutilization is a process that can greatly harm the health and well-being of a patient as well as unnecessarily drive up costs," she said.
Hoste added there are other important changes that need to be made to the no-fault law, to make sure people with severe injuries are getting the care they need.
One is to set reasonable rates for medical services for care of catastrophically injured crash survivors. In most cases, the law currently allows insurance companies to pay less than the actual cost of care.
He said the other change needed is to allow family caregivers to be paid for all of the hours they care for an injured loved one. Currently, the law says family and friend caregivers can be paid for a total of 56 hours of care, even if the survivor needs more hours of care than that.
Those bills are expected to be introduced when the state Legislature returns to Lansing in the fall.
