| 1 | 1 | | HOUSE BILL NO. 4922 A bill to amend 1978 PA 368, entitled "Public health code," by amending sections 24502, 24503, 24504, 24507, 24509, 24510, 24511, and 24513 (MCL 333.24502, 333.24503, 333.24504, 333.24507, 333.24509, 333.24510, 333.24511, and 333.24513), sections 24502, 24503, 24504, 24507, 24510, 24511, and 24513 as added by 2020 PA 234 and section 24509 as added by 2020 PA 235. the people of the state of michigan enact: Sec. 24502. (1) "Carrier" means any of the following: (a) A person that issues a health benefit plan in this state, including an insurer, health maintenance organization, or any other person providing a plan of health benefits, coverage, or insurance subject to state insurance regulation. (b) An entity that contracts with this state or a local unit of government to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services provided under a self-funded plan established or maintained by the state or local unit of government for its employees. (2) "Department" means the department of insurance and financial services. (3) "Director" means the director of the department or his or her designee. (4) "Emergency medical services operation" means any of the following: (a) A medical first response service as that term is defined in section 20906. (b) A nontransport prehospital life support operation as that term is defined in section 20908. (c) An ambulance operation as that term is defined in section 20902 if the ambulance operation is transporting any of the following by an ambulance that is a motor vehicle: (i) A nonemergency patient. (ii) An emergency patient. (5) (4) "Emergency patient" means an individual with a physical or mental condition that manifests itself by acute symptoms of sufficient severity, including, but not limited to, pain such that a prudent layperson, possessing average knowledge of health and medicine, could reasonably expect to result in 1 or more of the following: (a) Placing the health of the individual or, in the case of a pregnant woman, the health of the woman or the unborn child, or both, in serious jeopardy. (b) Serious impairment of bodily function. (c) Serious dysfunction of a body organ or part. (6) (5) "Health benefit plan" means an individual or group expense-incurred hospital, medical, or surgical policy or certificate, an individual or group health maintenance organization contract, or a self-funded plan established or maintained by this state or a local unit of government for its employees. Health benefit plan does not include accident-only, credit, dental, or disability income insurance; long-term care insurance; coverage issued as a supplement to liability insurance; coverage only for a specified disease or illness; worker's compensation or similar insurance; or automobile medical-payment insurance. (7) (6) "Health care service" means a diagnostic procedure, medical or surgical procedure, examination, or other treatment or service, or a service delivered through an emergency medical services operation. (8) (7) "Health facility" means any of the following: (a) A hospital. (b) A freestanding surgical outpatient facility as that term is defined in section 20104. (c) A skilled nursing facility as that term is defined in section 20109. (d) A physician's office or other outpatient setting, that is not otherwise described in this subsection. (e) A laboratory. (f) A radiology or imaging center. (9) (8) "Health maintenance organization" means that term as defined in section 3501 of the insurance code of 1956, 1956 PA 218, MCL 500.3501. (10) (9) "Hospital" means that term as defined in section 20106. (11) (10) "Insurer" means that term as defined in section 106 of the insurance code of 1956, 1956 PA 218, MCL 500.106. Sec. 24503. (1) "Local unit of government" means that term as defined in section 1 of 2006 PA 495, MCL 550.1951. (2) "Nonemergency patient" means an individual whose physical or mental condition is such that the individual may reasonably be suspected of not being in imminent danger of loss of life or of significant health impairment. (3) "Nonparticipating emergency medical services operation" means an emergency medical services operation that is not a participating emergency medical services operation. (4) (3) "Nonparticipating health facility" means a health facility that is not a participating health facility. (5) (4) "Nonparticipating provider" means a provider who is not a participating provider. Sec. 24504. (1) "Participating emergency medical services operation" means an emergency medical services operation that, under contract with a carrier, or with the carrier's contractor or subcontractor, agrees to provide health care services to individuals who are covered by health benefit plans issued or administered by the carrier and to accept payment by the carrier, contractor, or subcontractor for the services covered by the health benefit plans as payment in full, other than coinsurance, copayments, or deductibles. (2) (1) "Participating health facility" means a health facility that, under contract with a carrier, or with the carrier's contractor or subcontractor, agrees to provide health care services to individuals who are covered by health benefit plans issued or administered by the carrier and to accept payment by the carrier, contractor, or subcontractor for the services covered by the health benefit plans as payment in full, other than coinsurance, copayments, or deductibles. (3) (2) "Participating provider" means a provider who, under contract with a carrier, or with the carrier's contractor or subcontractor, agrees to provide health care services to individuals who are covered by health benefit plans issued or administered by the carrier and to accept payment by the carrier, contractor, or subcontractor for the services covered by the health benefit plans as payment in full, other than coinsurance, copayments, or deductibles. (4) (3) "Patient's representative" means any of the following: (a) A person to whom a nonemergency patient has given express written consent to represent the patient. (b) A person authorized by law to provide consent for a nonemergency patient. (c) A provider who is treating a nonemergency patient, but only if the patient is unable to provide consent. (5) (4) "Provider" means an any of the following: (a) An individual who is licensed, registered, or otherwise authorized to engage in a health profession under article 15, but does not include a dentist licensed under part 166. (b) A medical first responder, emergency medical technician, emergency medical technician specialist, or paramedic licensed under article 17. Sec. 24507. (1) Subsection (2) applies to a nonparticipating provider who or a nonparticipating emergency medical services operation that is providing a health care service if any of the following apply: (a) The health care service is provided to an emergency patient, is covered by the emergency patient's health benefit plan, and is provided to the emergency patient by the nonparticipating provider at a participating health facility or nonparticipating health facility. (b) The health care service is provided to a nonemergency patient, is covered by the nonemergency patient's health benefit plan, and is provided to the nonemergency patient by an emergency medical services operation as defined in section 24502(4)(c) that is a nonparticipating emergency medical services operation. (c) (b) All of the following apply: (i) The health care service is provided to a nonemergency patient. (ii) The health care service is covered by the nonemergency patient's health benefit plan. (iii) The health care service is provided to the nonemergency patient by the nonparticipating provider at a participating health facility. (iv) Either of the following: (A) The nonemergency patient does not have the ability or opportunity to choose a participating provider. (B) The nonemergency patient has not been provided the disclosure required under section 24509. (d) (c) The health care service is provided by the nonparticipating provider at a hospital that is a participating health facility to an emergency patient who was admitted to the hospital within 72 hours after receiving a health care service in the hospital's emergency room. (2) Except as otherwise provided in section 24511 or 24513 and subject to subsection (4), if any of the circumstances described in subsection (1) apply, the nonparticipating provider or the nonparticipating emergency medical services operation shall submit a claim to the patient's carrier within 60 days after the date of the health care service and shall accept from the patient's carrier, as payment in full, the greater of the following: (a) Subject to section 24510, the median amount negotiated by the patient's carrier for the region and provider specialty, excluding any in-network coinsurance, copayments, or deductibles. The patient's carrier shall determine the region and provider specialty for purposes of this subdivision. (b) One hundred and fifty percent of the Medicare fee for service fee schedule for the health care service provided, excluding any in-network coinsurance, copayments, or deductibles. (3) If the circumstance described in subsection (1)(c) (1)(d) applies, this section applies to any health care service provided by a nonparticipating provider to the emergency patient during his or her hospital stay. (4) A patient's carrier shall pay the amount described in subsection (2) to the nonparticipating provider or nonparticipating emergency medical services operation within 60 days after receiving the claim from the nonparticipating provider or nonparticipating emergency medical services operation under subsection (2). The nonparticipating provider or nonparticipating emergency medical services operation shall not collect or attempt to collect from the patient any amount other than the applicable in-network coinsurance, copayment, or deductible. Sec. 24509. (1) Subject to subsection (2), a nonparticipating provider who is providing a health care service to a nonemergency patient shall provide the disclosure described in subsection (3) to the nonemergency patient at the earliest of the following: (a) If the health care service was scheduled and is being provided in a health facility described in section 24502(7)(a), 24502(8)(a), (b), (c), (e), or (f), at least 14 days before providing the health care service or, if the health care service will be provided within 14 days after scheduling the health care service, within 14 days. (b) If the health care service is being provided in a health facility described in section 24502(7)(d), 24502(8)(d), at the time of the nonparticipating provider's first contact with the nonemergency patient regarding the health care service. (c) During 1 of the following: (i) A presurgical consultation for the health care service. (ii) A scheduling or intake call for the health care service. (iii) A preoperative review for the health care service. (iv) Any other contact occurring before a health care service that is similar to a contact described in subparagraph (i), (ii), or (iii). (2) A nonparticipating provider shall not provide the disclosure described in subsection (3) to a nonemergency patient at the time of the nonemergency patient's admittance to a health facility described in section 24502(7)(a), 24502(8)(a), (b), (c), (e), or (f), or at the time of preparing the nonemergency patient for a surgery or another medical procedure. (3) The disclosure required under subsection (1) must be in not less than 12-point type and in substantially the following form: "Your health benefit plan may or may not provide coverage for all of the health care services you are scheduled to receive or the providers providing those services. You may be responsible for the costs of the services that are not covered by your health benefit plan. The nonparticipating provider must provide a good-faith estimate of the cost of the health care services to be provided. A good-faith estimate does not take into account unforeseen circumstances, which may affect the cost of the health care services provided. You also have a right to request that the health care services be performed by a provider that participates with your health benefit plan, and may contact your carrier to arrange for those services to be provided at a lower cost and to receive information on in-network providers who can perform the health care services that you need. I have received, read, and understand this disclosure. __________________________________________________ _________ (Patient or patient's representative's signature) (Date) __________________________________________________ (Type or print name of patient or patient's representative)". (4) A nonparticipating provider shall do all of the following: (a) Complete the disclosure described in subsection (3) and, after completing the disclosure, obtain on the disclosure the signature of the nonemergency patient, or that patient's representative, acknowledging that the nonemergency patient, or that patient's representative, has received, has read, and understands the disclosure. (b) Retain a copy of the disclosure required under this section for not less than 7 years. (c) Provide the nonemergency patient or that patient's representative with a good-faith estimate of the cost of the health care services to be provided to the nonemergency patient. (5) Except as otherwise provided in section 24513 and subject to subsection (6), a nonparticipating provider who fails to provide the disclosure as required under this section shall submit a claim to the nonemergency patient's carrier within 60 days after the date of the health care service and shall accept from the nonemergency patient's carrier, as payment in full, the greater of the following: (a) Subject to section 24510, the median amount negotiated by the nonemergency patient's carrier for the region and provider specialty, excluding any in-network coinsurance, copayments, or deductibles. The nonemergency patient's carrier shall determine the region and provider specialty for purposes of this subdivision. (b) One hundred and fifty percent of the Medicare fee for service fee schedule for the health care service provided, excluding any in-network coinsurance, copayments, or deductibles. (6) A nonemergency patient's carrier shall pay the amount described in subsection (5) to the nonparticipating provider within 60 days after receiving the claim from the nonparticipating provider under subsection (5). The nonparticipating provider shall not collect or attempt to collect from the nonemergency patient any amount other than the applicable in-network coinsurance, copayment, or deductible. (7) This section does not apply to a nonparticipating emergency medical services operation. Sec. 24510. (1) Beginning July 1, 2021, if a nonparticipating provider or nonparticipating emergency medical services operation believes that the amount described in section 24507(2)(a) or 24509(5)(a), as applicable, was incorrectly calculated, the nonparticipating provider or nonparticipating emergency medical services operation may make a request to the department for a review of the calculation. The request must be made on a form and in a manner required by the department. (2) The department may request data on the median amount negotiated by the patient's carrier with participating providers or any documents, materials, or other information that the department believes is necessary to assist the department in reviewing the calculation described in subsection (1) and may consult an external database that contains the negotiated rates under the patient's health benefit plan for the applicable health care service. For purposes of conducting a review under this section, any data, documents, materials, or other information requested by the department must only be submitted to the department. (3) If, after conducting its review under this section, the department determines that the amount described in section 24507(2)(a) or 24509(5)(a), as applicable, was incorrectly calculated, the department shall determine the correct amount. A nonparticipating provider or nonparticipating emergency medical services operation shall not file a subsequent request for a review under subsection (1) if the request involves the same rate calculation for a health care service for which the nonparticipating provider or nonparticipating emergency medical services operation has previously received a determination from the department under this section. (4) All of the following apply to any data, documents, materials, or other information described in subsection (2) that are in the possession or control of the department and that are obtained by, created by, or disclosed to the director or a department employee for purposes of this section: (a) The data, documents, materials, or other information is considered proprietary and to contain trade secrets. (b) The data, documents, materials, or other information are confidential and privileged and are not subject to disclosure under the freedom of information act, 1976 PA 442, MCL 15.231 to 15.246. (c) The data, documents, materials, or other information are not subject to subpoena and are not subject to discovery or admissible in evidence in any private civil action. (5) The director or a department employee who receives data, documents, materials, or other information under this section shall not testify in any private civil action concerning the data, documents, materials, or information. Sec. 24511. (1) A nonparticipating provider who or nonparticipating emergency medical services operation that provides a health care service involving a complicating factor to an emergency patient described in section 24507(1)(a) or (c) (d) may file a claim with a carrier for a reimbursement amount that is greater than the amount described in section 24507(2). The claim must be accompanied by both of the following: (a) Clinical documentation demonstrating the complicating factor. (b) The emergency patient's medical record for the health care service, with the portions of the record supporting the complicating factor highlighted. (2) A carrier shall do 1 of the following within 30 days after receiving the claim described in subsection (1): (a) If the carrier determines that the documentation submitted with the claim demonstrates a complicating factor, make 1 additional payment that is 25% of the amount provided under section 24507(2)(a). (b) If the carrier determines that the documentation submitted with the claim does not demonstrate a complicating factor, issue a letter to the nonparticipating provider denying the claim. (3) If a carrier denies a claim under subsection (2), beginning July 1, 2021, the nonparticipating provider or nonparticipating emergency medical services operation may file a written request for binding arbitration with the department on a form and in a manner required by the department. The department shall accept the request for binding arbitration if the department receives all of the following from the nonparticipating provider or nonparticipating emergency medical services operation: (a) The documentation that the nonparticipating provider or nonparticipating emergency medical services operation submitted to the carrier under subsection (1). (b) The contact information for the emergency patient's health benefit plan. (c) The denial letter described in subsection (2). (4) If the request for binding arbitration under subsection (3) is accepted by the department, the department shall notify the carrier. Within 30 days after receiving the department's notification under this subsection, the carrier shall submit written documentation to the department either confirming the carrier's denial or providing an alternative payment offer to be considered in the arbitration process. (5) The department shall create and maintain a list of arbitrators approved by the department who are trained by the American Arbitration Association or American Health Lawyers Association for purposes of providing binding arbitration under this section. The parties to the arbitration shall agree on an arbitrator from the department's list. The arbitration must include a review of written submissions by both parties, including alternative payment offers, and the arbitrator shall provide a written decision within 45 days after receiving the documentation submitted by the parties. In making a determination, the arbitrator shall consider documentation supporting the use of a procedure code or modifier for care provided beyond the usual health care service and any of the following: (a) Increased intensity, time, or technical difficulty of the health care service. (b) The severity of the patient's condition. (c) The physical or mental effort required in providing the health care service. (6) The nonparticipating provider or nonparticipating emergency medical services operation and the carrier shall each pay 1/2 of the total costs of the arbitration proceeding. A nonparticipating provider or nonparticipating emergency medical services operation participating in arbitration under this section shall not collect or attempt to collect from the patient any amount other than the applicable in-network coinsurance, copayment, or deductible. (7) This section does not limit any other review process provided under this article. (8) As used in this section, "complicating factor" means a factor that is not normally incident to a health care service, including, but not limited to, the following: (a) Increased intensity, time, or technical difficulty of the health care service. (b) The severity of the patient's condition. (c) The physical or mental effort required in providing the health care service. Sec. 24513. This article does not prohibit a carrier and a nonparticipating provider and a carrier or nonparticipating emergency medical services operation from agreeing, through private negotiations or an internal dispute resolution process, to a payment amount that is greater than the amounts described in section 24507(2) or 24509(5). A nonparticipating provider or nonparticipating emergency medical services operation entering into an agreement authorized under this section shall not collect or attempt to collect from the patient any amount other than the applicable in-network coinsurance, copayment, or deductible. |
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| 27 | 27 | | HOUSE BILL NO. 4922 |
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| 30 | 30 | | |
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| 31 | 31 | | A bill to amend 1978 PA 368, entitled |
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| 32 | 32 | | |
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| 33 | 33 | | "Public health code," |
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| 34 | 34 | | |
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| 35 | 35 | | by amending sections 24502, 24503, 24504, 24507, 24509, 24510, 24511, and 24513 (MCL 333.24502, 333.24503, 333.24504, 333.24507, 333.24509, 333.24510, 333.24511, and 333.24513), sections 24502, 24503, 24504, 24507, 24510, 24511, and 24513 as added by 2020 PA 234 and section 24509 as added by 2020 PA 235. |
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| 36 | 36 | | |
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| 37 | 37 | | the people of the state of michigan enact: |
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| 38 | 38 | | |
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| 39 | 39 | | Sec. 24502. (1) "Carrier" means any of the following: |
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| 40 | 40 | | |
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| 41 | 41 | | (a) A person that issues a health benefit plan in this state, including an insurer, health maintenance organization, or any other person providing a plan of health benefits, coverage, or insurance subject to state insurance regulation. |
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| 42 | 42 | | |
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| 43 | 43 | | (b) An entity that contracts with this state or a local unit of government to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services provided under a self-funded plan established or maintained by the state or local unit of government for its employees. |
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| 45 | 45 | | (2) "Department" means the department of insurance and financial services. |
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| 46 | 46 | | |
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| 47 | 47 | | (3) "Director" means the director of the department or his or her designee. |
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| 48 | 48 | | |
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| 49 | 49 | | (4) "Emergency medical services operation" means any of the following: |
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| 51 | 51 | | (a) A medical first response service as that term is defined in section 20906. |
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| 52 | 52 | | |
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| 53 | 53 | | (b) A nontransport prehospital life support operation as that term is defined in section 20908. |
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| 54 | 54 | | |
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| 55 | 55 | | (c) An ambulance operation as that term is defined in section 20902 if the ambulance operation is transporting any of the following by an ambulance that is a motor vehicle: |
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| 56 | 56 | | |
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| 57 | 57 | | (i) A nonemergency patient. |
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| 58 | 58 | | |
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| 59 | 59 | | (ii) An emergency patient. |
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| 60 | 60 | | |
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| 61 | 61 | | (5) (4) "Emergency patient" means an individual with a physical or mental condition that manifests itself by acute symptoms of sufficient severity, including, but not limited to, pain such that a prudent layperson, possessing average knowledge of health and medicine, could reasonably expect to result in 1 or more of the following: |
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| 63 | 63 | | (a) Placing the health of the individual or, in the case of a pregnant woman, the health of the woman or the unborn child, or both, in serious jeopardy. |
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| 64 | 64 | | |
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| 65 | 65 | | (b) Serious impairment of bodily function. |
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| 66 | 66 | | |
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| 67 | 67 | | (c) Serious dysfunction of a body organ or part. |
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| 68 | 68 | | |
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| 69 | 69 | | (6) (5) "Health benefit plan" means an individual or group expense-incurred hospital, medical, or surgical policy or certificate, an individual or group health maintenance organization contract, or a self-funded plan established or maintained by this state or a local unit of government for its employees. Health benefit plan does not include accident-only, credit, dental, or disability income insurance; long-term care insurance; coverage issued as a supplement to liability insurance; coverage only for a specified disease or illness; worker's compensation or similar insurance; or automobile medical-payment insurance. |
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| 70 | 70 | | |
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| 71 | 71 | | (7) (6) "Health care service" means a diagnostic procedure, medical or surgical procedure, examination, or other treatment or service, or a service delivered through an emergency medical services operation. |
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| 72 | 72 | | |
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| 73 | 73 | | (8) (7) "Health facility" means any of the following: |
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| 74 | 74 | | |
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| 75 | 75 | | (a) A hospital. |
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| 77 | 77 | | (b) A freestanding surgical outpatient facility as that term is defined in section 20104. |
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| 78 | 78 | | |
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| 79 | 79 | | (c) A skilled nursing facility as that term is defined in section 20109. |
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| 80 | 80 | | |
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| 81 | 81 | | (d) A physician's office or other outpatient setting, that is not otherwise described in this subsection. |
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| 83 | 83 | | (e) A laboratory. |
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| 85 | 85 | | (f) A radiology or imaging center. |
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| 87 | 87 | | (9) (8) "Health maintenance organization" means that term as defined in section 3501 of the insurance code of 1956, 1956 PA 218, MCL 500.3501. |
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| 89 | 89 | | (10) (9) "Hospital" means that term as defined in section 20106. |
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| 91 | 91 | | (11) (10) "Insurer" means that term as defined in section 106 of the insurance code of 1956, 1956 PA 218, MCL 500.106. |
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| 93 | 93 | | Sec. 24503. (1) "Local unit of government" means that term as defined in section 1 of 2006 PA 495, MCL 550.1951. |
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| 94 | 94 | | |
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| 95 | 95 | | (2) "Nonemergency patient" means an individual whose physical or mental condition is such that the individual may reasonably be suspected of not being in imminent danger of loss of life or of significant health impairment. |
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| 97 | 97 | | (3) "Nonparticipating emergency medical services operation" means an emergency medical services operation that is not a participating emergency medical services operation. |
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| 99 | 99 | | (4) (3) "Nonparticipating health facility" means a health facility that is not a participating health facility. |
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| 100 | 100 | | |
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| 101 | 101 | | (5) (4) "Nonparticipating provider" means a provider who is not a participating provider. |
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| 102 | 102 | | |
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| 103 | 103 | | Sec. 24504. (1) "Participating emergency medical services operation" means an emergency medical services operation that, under contract with a carrier, or with the carrier's contractor or subcontractor, agrees to provide health care services to individuals who are covered by health benefit plans issued or administered by the carrier and to accept payment by the carrier, contractor, or subcontractor for the services covered by the health benefit plans as payment in full, other than coinsurance, copayments, or deductibles. |
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| 105 | 105 | | (2) (1) "Participating health facility" means a health facility that, under contract with a carrier, or with the carrier's contractor or subcontractor, agrees to provide health care services to individuals who are covered by health benefit plans issued or administered by the carrier and to accept payment by the carrier, contractor, or subcontractor for the services covered by the health benefit plans as payment in full, other than coinsurance, copayments, or deductibles. |
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| 107 | 107 | | (3) (2) "Participating provider" means a provider who, under contract with a carrier, or with the carrier's contractor or subcontractor, agrees to provide health care services to individuals who are covered by health benefit plans issued or administered by the carrier and to accept payment by the carrier, contractor, or subcontractor for the services covered by the health benefit plans as payment in full, other than coinsurance, copayments, or deductibles. |
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| 109 | 109 | | (4) (3) "Patient's representative" means any of the following: |
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| 111 | 111 | | (a) A person to whom a nonemergency patient has given express written consent to represent the patient. |
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| 113 | 113 | | (b) A person authorized by law to provide consent for a nonemergency patient. |
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| 115 | 115 | | (c) A provider who is treating a nonemergency patient, but only if the patient is unable to provide consent. |
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| 117 | 117 | | (5) (4) "Provider" means an any of the following: |
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| 119 | 119 | | (a) An individual who is licensed, registered, or otherwise authorized to engage in a health profession under article 15, but does not include a dentist licensed under part 166. |
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| 121 | 121 | | (b) A medical first responder, emergency medical technician, emergency medical technician specialist, or paramedic licensed under article 17. |
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| 123 | 123 | | Sec. 24507. (1) Subsection (2) applies to a nonparticipating provider who or a nonparticipating emergency medical services operation that is providing a health care service if any of the following apply: |
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| 125 | 125 | | (a) The health care service is provided to an emergency patient, is covered by the emergency patient's health benefit plan, and is provided to the emergency patient by the nonparticipating provider at a participating health facility or nonparticipating health facility. |
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| 126 | 126 | | |
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| 127 | 127 | | (b) The health care service is provided to a nonemergency patient, is covered by the nonemergency patient's health benefit plan, and is provided to the nonemergency patient by an emergency medical services operation as defined in section 24502(4)(c) that is a nonparticipating emergency medical services operation. |
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| 129 | 129 | | (c) (b) All of the following apply: |
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| 131 | 131 | | (i) The health care service is provided to a nonemergency patient. |
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| 133 | 133 | | (ii) The health care service is covered by the nonemergency patient's health benefit plan. |
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| 134 | 134 | | |
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| 135 | 135 | | (iii) The health care service is provided to the nonemergency patient by the nonparticipating provider at a participating health facility. |
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| 136 | 136 | | |
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| 137 | 137 | | (iv) Either of the following: |
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| 138 | 138 | | |
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| 139 | 139 | | (A) The nonemergency patient does not have the ability or opportunity to choose a participating provider. |
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| 140 | 140 | | |
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| 141 | 141 | | (B) The nonemergency patient has not been provided the disclosure required under section 24509. |
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| 142 | 142 | | |
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| 143 | 143 | | (d) (c) The health care service is provided by the nonparticipating provider at a hospital that is a participating health facility to an emergency patient who was admitted to the hospital within 72 hours after receiving a health care service in the hospital's emergency room. |
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| 144 | 144 | | |
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| 145 | 145 | | (2) Except as otherwise provided in section 24511 or 24513 and subject to subsection (4), if any of the circumstances described in subsection (1) apply, the nonparticipating provider or the nonparticipating emergency medical services operation shall submit a claim to the patient's carrier within 60 days after the date of the health care service and shall accept from the patient's carrier, as payment in full, the greater of the following: |
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| 146 | 146 | | |
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| 147 | 147 | | (a) Subject to section 24510, the median amount negotiated by the patient's carrier for the region and provider specialty, excluding any in-network coinsurance, copayments, or deductibles. The patient's carrier shall determine the region and provider specialty for purposes of this subdivision. |
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| 148 | 148 | | |
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| 149 | 149 | | (b) One hundred and fifty percent of the Medicare fee for service fee schedule for the health care service provided, excluding any in-network coinsurance, copayments, or deductibles. |
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| 150 | 150 | | |
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| 151 | 151 | | (3) If the circumstance described in subsection (1)(c) (1)(d) applies, this section applies to any health care service provided by a nonparticipating provider to the emergency patient during his or her hospital stay. |
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| 152 | 152 | | |
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| 153 | 153 | | (4) A patient's carrier shall pay the amount described in subsection (2) to the nonparticipating provider or nonparticipating emergency medical services operation within 60 days after receiving the claim from the nonparticipating provider or nonparticipating emergency medical services operation under subsection (2). The nonparticipating provider or nonparticipating emergency medical services operation shall not collect or attempt to collect from the patient any amount other than the applicable in-network coinsurance, copayment, or deductible. |
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| 154 | 154 | | |
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| 155 | 155 | | Sec. 24509. (1) Subject to subsection (2), a nonparticipating provider who is providing a health care service to a nonemergency patient shall provide the disclosure described in subsection (3) to the nonemergency patient at the earliest of the following: |
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| 156 | 156 | | |
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| 157 | 157 | | (a) If the health care service was scheduled and is being provided in a health facility described in section 24502(7)(a), 24502(8)(a), (b), (c), (e), or (f), at least 14 days before providing the health care service or, if the health care service will be provided within 14 days after scheduling the health care service, within 14 days. |
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| 158 | 158 | | |
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| 159 | 159 | | (b) If the health care service is being provided in a health facility described in section 24502(7)(d), 24502(8)(d), at the time of the nonparticipating provider's first contact with the nonemergency patient regarding the health care service. |
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| 160 | 160 | | |
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| 161 | 161 | | (c) During 1 of the following: |
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| 162 | 162 | | |
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| 163 | 163 | | (i) A presurgical consultation for the health care service. |
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| 164 | 164 | | |
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| 165 | 165 | | (ii) A scheduling or intake call for the health care service. |
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| 166 | 166 | | |
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| 167 | 167 | | (iii) A preoperative review for the health care service. |
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| 168 | 168 | | |
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| 169 | 169 | | (iv) Any other contact occurring before a health care service that is similar to a contact described in subparagraph (i), (ii), or (iii). |
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| 170 | 170 | | |
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| 171 | 171 | | (2) A nonparticipating provider shall not provide the disclosure described in subsection (3) to a nonemergency patient at the time of the nonemergency patient's admittance to a health facility described in section 24502(7)(a), 24502(8)(a), (b), (c), (e), or (f), or at the time of preparing the nonemergency patient for a surgery or another medical procedure. |
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| 172 | 172 | | |
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| 173 | 173 | | (3) The disclosure required under subsection (1) must be in not less than 12-point type and in substantially the following form: |
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| 174 | 174 | | |
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| 175 | 175 | | "Your health benefit plan may or may not provide coverage for all of the health care services you are scheduled to receive or the providers providing those services. You may be responsible for the costs of the services that are not covered by your health benefit plan. |
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| 176 | 176 | | |
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| 177 | 177 | | The nonparticipating provider must provide a good-faith estimate of the cost of the health care services to be provided. A good-faith estimate does not take into account unforeseen circumstances, which may affect the cost of the health care services provided. |
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| 178 | 178 | | |
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| 179 | 179 | | You also have a right to request that the health care services be performed by a provider that participates with your health benefit plan, and may contact your carrier to arrange for those services to be provided at a lower cost and to receive information on in-network providers who can perform the health care services that you need. |
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| 180 | 180 | | |
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| 181 | 181 | | I have received, read, and understand this disclosure. |
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| 182 | 182 | | |
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| 183 | 183 | | __________________________________________________ _________ |
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| 184 | 184 | | |
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| 185 | 185 | | (Patient or patient's representative's signature) (Date) |
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| 186 | 186 | | |
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| 187 | 187 | | __________________________________________________ |
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| 188 | 188 | | |
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| 189 | 189 | | (Type or print name of patient or patient's representative)". |
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| 190 | 190 | | |
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| 191 | 191 | | (4) A nonparticipating provider shall do all of the following: |
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| 192 | 192 | | |
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| 193 | 193 | | (a) Complete the disclosure described in subsection (3) and, after completing the disclosure, obtain on the disclosure the signature of the nonemergency patient, or that patient's representative, acknowledging that the nonemergency patient, or that patient's representative, has received, has read, and understands the disclosure. |
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| 194 | 194 | | |
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| 195 | 195 | | (b) Retain a copy of the disclosure required under this section for not less than 7 years. |
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| 196 | 196 | | |
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| 197 | 197 | | (c) Provide the nonemergency patient or that patient's representative with a good-faith estimate of the cost of the health care services to be provided to the nonemergency patient. |
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| 198 | 198 | | |
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| 199 | 199 | | (5) Except as otherwise provided in section 24513 and subject to subsection (6), a nonparticipating provider who fails to provide the disclosure as required under this section shall submit a claim to the nonemergency patient's carrier within 60 days after the date of the health care service and shall accept from the nonemergency patient's carrier, as payment in full, the greater of the following: |
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| 200 | 200 | | |
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| 201 | 201 | | (a) Subject to section 24510, the median amount negotiated by the nonemergency patient's carrier for the region and provider specialty, excluding any in-network coinsurance, copayments, or deductibles. The nonemergency patient's carrier shall determine the region and provider specialty for purposes of this subdivision. |
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| 202 | 202 | | |
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| 203 | 203 | | (b) One hundred and fifty percent of the Medicare fee for service fee schedule for the health care service provided, excluding any in-network coinsurance, copayments, or deductibles. |
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| 204 | 204 | | |
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| 205 | 205 | | (6) A nonemergency patient's carrier shall pay the amount described in subsection (5) to the nonparticipating provider within 60 days after receiving the claim from the nonparticipating provider under subsection (5). The nonparticipating provider shall not collect or attempt to collect from the nonemergency patient any amount other than the applicable in-network coinsurance, copayment, or deductible. |
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| 206 | 206 | | |
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| 207 | 207 | | (7) This section does not apply to a nonparticipating emergency medical services operation. |
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| 208 | 208 | | |
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| 209 | 209 | | Sec. 24510. (1) Beginning July 1, 2021, if a nonparticipating provider or nonparticipating emergency medical services operation believes that the amount described in section 24507(2)(a) or 24509(5)(a), as applicable, was incorrectly calculated, the nonparticipating provider or nonparticipating emergency medical services operation may make a request to the department for a review of the calculation. The request must be made on a form and in a manner required by the department. |
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| 210 | 210 | | |
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| 211 | 211 | | (2) The department may request data on the median amount negotiated by the patient's carrier with participating providers or any documents, materials, or other information that the department believes is necessary to assist the department in reviewing the calculation described in subsection (1) and may consult an external database that contains the negotiated rates under the patient's health benefit plan for the applicable health care service. For purposes of conducting a review under this section, any data, documents, materials, or other information requested by the department must only be submitted to the department. |
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| 212 | 212 | | |
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| 213 | 213 | | (3) If, after conducting its review under this section, the department determines that the amount described in section 24507(2)(a) or 24509(5)(a), as applicable, was incorrectly calculated, the department shall determine the correct amount. A nonparticipating provider or nonparticipating emergency medical services operation shall not file a subsequent request for a review under subsection (1) if the request involves the same rate calculation for a health care service for which the nonparticipating provider or nonparticipating emergency medical services operation has previously received a determination from the department under this section. |
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| 214 | 214 | | |
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| 215 | 215 | | (4) All of the following apply to any data, documents, materials, or other information described in subsection (2) that are in the possession or control of the department and that are obtained by, created by, or disclosed to the director or a department employee for purposes of this section: |
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| 216 | 216 | | |
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| 217 | 217 | | (a) The data, documents, materials, or other information is considered proprietary and to contain trade secrets. |
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| 218 | 218 | | |
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| 219 | 219 | | (b) The data, documents, materials, or other information are confidential and privileged and are not subject to disclosure under the freedom of information act, 1976 PA 442, MCL 15.231 to 15.246. |
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| 220 | 220 | | |
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| 221 | 221 | | (c) The data, documents, materials, or other information are not subject to subpoena and are not subject to discovery or admissible in evidence in any private civil action. |
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| 222 | 222 | | |
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| 223 | 223 | | (5) The director or a department employee who receives data, documents, materials, or other information under this section shall not testify in any private civil action concerning the data, documents, materials, or information. |
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| 224 | 224 | | |
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| 225 | 225 | | Sec. 24511. (1) A nonparticipating provider who or nonparticipating emergency medical services operation that provides a health care service involving a complicating factor to an emergency patient described in section 24507(1)(a) or (c) (d) may file a claim with a carrier for a reimbursement amount that is greater than the amount described in section 24507(2). The claim must be accompanied by both of the following: |
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| 226 | 226 | | |
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| 227 | 227 | | (a) Clinical documentation demonstrating the complicating factor. |
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| 228 | 228 | | |
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| 229 | 229 | | (b) The emergency patient's medical record for the health care service, with the portions of the record supporting the complicating factor highlighted. |
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| 230 | 230 | | |
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| 231 | 231 | | (2) A carrier shall do 1 of the following within 30 days after receiving the claim described in subsection (1): |
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| 232 | 232 | | |
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| 233 | 233 | | (a) If the carrier determines that the documentation submitted with the claim demonstrates a complicating factor, make 1 additional payment that is 25% of the amount provided under section 24507(2)(a). |
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| 234 | 234 | | |
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| 235 | 235 | | (b) If the carrier determines that the documentation submitted with the claim does not demonstrate a complicating factor, issue a letter to the nonparticipating provider denying the claim. |
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| 236 | 236 | | |
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| 237 | 237 | | (3) If a carrier denies a claim under subsection (2), beginning July 1, 2021, the nonparticipating provider or nonparticipating emergency medical services operation may file a written request for binding arbitration with the department on a form and in a manner required by the department. The department shall accept the request for binding arbitration if the department receives all of the following from the nonparticipating provider or nonparticipating emergency medical services operation: |
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| 238 | 238 | | |
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| 239 | 239 | | (a) The documentation that the nonparticipating provider or nonparticipating emergency medical services operation submitted to the carrier under subsection (1). |
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| 240 | 240 | | |
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| 241 | 241 | | (b) The contact information for the emergency patient's health benefit plan. |
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| 242 | 242 | | |
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| 243 | 243 | | (c) The denial letter described in subsection (2). |
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| 244 | 244 | | |
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| 245 | 245 | | (4) If the request for binding arbitration under subsection (3) is accepted by the department, the department shall notify the carrier. Within 30 days after receiving the department's notification under this subsection, the carrier shall submit written documentation to the department either confirming the carrier's denial or providing an alternative payment offer to be considered in the arbitration process. |
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| 246 | 246 | | |
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| 247 | 247 | | (5) The department shall create and maintain a list of arbitrators approved by the department who are trained by the American Arbitration Association or American Health Lawyers Association for purposes of providing binding arbitration under this section. The parties to the arbitration shall agree on an arbitrator from the department's list. The arbitration must include a review of written submissions by both parties, including alternative payment offers, and the arbitrator shall provide a written decision within 45 days after receiving the documentation submitted by the parties. In making a determination, the arbitrator shall consider documentation supporting the use of a procedure code or modifier for care provided beyond the usual health care service and any of the following: |
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| 248 | 248 | | |
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| 249 | 249 | | (a) Increased intensity, time, or technical difficulty of the health care service. |
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| 250 | 250 | | |
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| 251 | 251 | | (b) The severity of the patient's condition. |
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| 252 | 252 | | |
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| 253 | 253 | | (c) The physical or mental effort required in providing the health care service. |
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| 254 | 254 | | |
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| 255 | 255 | | (6) The nonparticipating provider or nonparticipating emergency medical services operation and the carrier shall each pay 1/2 of the total costs of the arbitration proceeding. A nonparticipating provider or nonparticipating emergency medical services operation participating in arbitration under this section shall not collect or attempt to collect from the patient any amount other than the applicable in-network coinsurance, copayment, or deductible. |
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| 256 | 256 | | |
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| 257 | 257 | | (7) This section does not limit any other review process provided under this article. |
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| 258 | 258 | | |
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| 259 | 259 | | (8) As used in this section, "complicating factor" means a factor that is not normally incident to a health care service, including, but not limited to, the following: |
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| 260 | 260 | | |
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| 261 | 261 | | (a) Increased intensity, time, or technical difficulty of the health care service. |
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| 262 | 262 | | |
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| 263 | 263 | | (b) The severity of the patient's condition. |
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| 264 | 264 | | |
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| 265 | 265 | | (c) The physical or mental effort required in providing the health care service. |
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| 266 | 266 | | |
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| 267 | 267 | | Sec. 24513. This article does not prohibit a carrier and a nonparticipating provider and a carrier or nonparticipating emergency medical services operation from agreeing, through private negotiations or an internal dispute resolution process, to a payment amount that is greater than the amounts described in section 24507(2) or 24509(5). A nonparticipating provider or nonparticipating emergency medical services operation entering into an agreement authorized under this section shall not collect or attempt to collect from the patient any amount other than the applicable in-network coinsurance, copayment, or deductible. |
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