By Electronic Medical Services and Direct Care Training & Resource Center, Inc.
A recent Michigan court ruling and guidance from the Department of Insurance and Financial Services (DIFS) underscore a critical point for post-acute care providers: reasonableness is not merely about what you charge—it also encompasses what you do, how you do it, and whether the insurer agrees that the service is needed and justified. For providers supporting catastrophically injured individuals, particularly under Michigan’s no-fault auto reform environment, this should not be taken lightly.
Too often, a provider inheriting a patient from another agency may implement what they believe are clinically superior or safer interventions—higher attendant care hours, closer nursing oversight, more rigorous behavioral strategies—without thoroughly documenting the basis for those changes. While the intention may be right, the approach can feel abrupt or even arrogant to insurers, especially if a prior provider delivered fewer services without significant documented failures.
Insurers retain the right to assess not only whether services are billed appropriately, but whether they are reasonable in scope and necessity. And this includes upgraded services after a change in provider. If the justification is lacking or poorly communicated, insurers may deny payment, leading to DIFS complaints or even litigation—an outcome no one desires.
Rather than anchoring in rigidity, providers are better served by adopting an approach grounded in humility, flexibility, and relationship-building. A suggested best practice: if upgraded services are necessary, propose a transitional period—perhaps 60 to 90 days—during which enhanced care levels are in place, accompanied by a formal medical or behavioral reassessment. This gives the insurer a pathway to reevaluate and providers an opportunity to demonstrate that changes were clinically sound and results-oriented.
In an evolving regulatory climate, credibility is currency. Providers must document well, communicate proactively, and show a willingness to adjust as needed. That mindset—not overconfidence—will preserve relationships, secure long-term cooperation from insurers, and ultimately, better serve the injured person at the center of the discussion.
Another Blog Post by Direct Care Training & Resource Center, Inc. Photos used are designed to complement the written content. They do not imply a relationship with or endorsement by any individual nor entity and may belong to their respective copyright holders.
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