One process that can be used when providers feel an insurer has acted unethically or has ignored market realities in pricing services is the Utilization process. This is available via the Michigan Department of Insurance and Financial Services. Its availability does not mean that litigation and negotiation cannot continue to be utilized.
It is a process that allows a provider to state their case, and seek a decision that fits in with both the financial and clinical obligations in any individual case. It’s good to note that there are documentation requirements. The image below shows what documents you are required to provide.
That said, one is not required but could be a relationship item worth noting and an item that effectively substantives your claim. That would be any documentation you sent to the insurer to make your case, based on this State of Michigan Administrative Statute:
_____________________________________________
R. 500.63. Requests for explanation
Rule 63.
(1) If a provider provides treatment, training, products, services, or accommodations to an injured person that are not usually associated with, are longer in duration than, are more frequent than, or extend over a greater number of days than the treatment, training, products, services, or accommodations usually required for the diagnosis or condition for which the injured person is being treated, the insurer or the association may request that the provider explain the necessity or indication for the treatment, training, products, services, or accommodations in writing. An insurer or the association may request that the provider include in its written explanation medical records, bills, and other information concerning the treatment, training, products, services, or accommodations.
(2) If an insurer or the association requests a provider to provide a written explanation under this rule, the request must be submitted to the provider within 30 days of the insurers or associations receipt of the bill related to the treatment, training, products, services, or accommodations.
(3) A provider that receives a request for a written explanation from an insurer or the association must respond within 30 days of receipt of the insurers or associations request.
(4) If an insurer’s or the associations request for records under subrule (1) of this rule requires the provider to provide medical records, bills, or other information in excess of that which customarily accompany a bill submitted to the insurer or the association, the insurer or the association must reimburse the provider at a reasonable and customary fee, plus the actual costs of copying and mailing, within 30 days of the insurers or associations request.
_______________________________________
It is so important to approach these matters correctly. Never hesitate to ask us how.
Social medica
______________________________________
A Blog Post prepared by Electronic Medical Services, LLC. Images used are for the purpose of complementing the written content. They are not meant to imply a relationship with or endorsement by any individual or entity and may belong to their respective copyright holders.
