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Michigan auto no-fault UR rule making nears finalization

August 6, 2020 · Optum Workers' Comp and Auto No-fault

Previously proposed Michigan auto no-fault utilization review (UR) rules (which were required by last year’s reform legislation) have moved to the next phase of the formal rule-making process, which is required review by a state legislative committee. Unless there are committee objections, the latest version, amended after comments by the state’s Department of Insurance and Financial Services (DIFS), should be adopted in the near future.

Rule contents

UR is defined under the auto reform law as “the initial evaluation by an insurer of the appropriateness in terms of both the level and the quality of treatment, products, services, or accommodations provided based on medically accepted standards,” while medically accepted standards means “the most appropriate practice guidelines for the treatment, training, products, services and accommodations provided to an injured person”. These practice guidelines may include generally accepted practice guidelines, evidence-based practice guidelines, or any other practice guidelines developed by the federal government or national or professional medical societies, boards, and associations. The UR process will be retrospective and is expected to evaluate both appropriateness and cost.

The rules, as amended and filed July 20, have been pared down from an earlier proposed version. The latest version addresses the overall UR process to be followed by providers and insurers. This includes:

  • Requests for records from providers by insurers
  • Review of treatment and determinations by insurers
  • Appeals by providers to DIFS
  • Certification (approval) of the insurer’s UR program by DIFS

The rules also briefly acknowledge the ability of insurers to contract with vendors to perform UR on their behalf. Specifically, the current version includes a simple statement that nothing in the rules should be construed to limit the ability of insurers to contract with a “medical review organization” (undefined) to perform UR activities on their behalf. However, an insurer that uses such a vendor remains responsible for full compliance.

Timelines

Given the timelines associated with all of this, we encourage clients to pay close attention to current activities from DIFS in relation to rule adoption and subsequent certification of their UR programs. Once finally adopted, the rules will apply to “treatment, training, products, services, and accommodations provided after July 1, 2020.” However, the rule text contains a built-in provision providing a 60-day implementation timeframe from the effective date for insurers to ensure their UR programs are actually in place.

Some other timeframes and requirements are not yet finalized. The aforementioned 60-day implementation time is not certification of an insurer’s UR program, as that is to take place annually based on a yet-to-be prescribed timeline from DIFS. However. the rules do note that each insurer will be required to submit a report to DIFS regarding UR data and activities by March 31 of each year. DIFS is also expected to publish various new forms sometime after final rule adoption.

Partnering with Optum

In anticipation of final rule adoption, Optum is developing procedures to assist our clients with compliance of their UR process. As this continues to develop, Optum will provide up to date information to our clients with the intent of offering relevant services to assist with related reviews and determinations. However, it is important to note that there remain some unknowns, contingent upon final approval of the rules and subsequent forms and timelines to be developed by DIFS.  

More information from Michigan on their auto reform law and related developments can be viewed online here. Should you have any questions, please reach out to your account manager. 


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