Michigan Surprise Billing Law

What insurance plans does the state law apply to?

Not all insurances are within reach of the Michigan Surprise Billing Law. Michigan’s law applies to health benefit plans subject to the state’s insurance regulations, including self-funded plans established or maintained by the state or local government for its employees.

What is the impact on Michigan providers?

The impact is significant if the Surprise Billing law is not carefully understood.  The law does not force out-of-network providers to become in-network.  If a physician chooses to remain out-of-network, they can and still balance bill the patient under certain circumstances in compliance with the law.

Balance Billing Prohibitions:  An out-of-network provider is prohibited from balance billing services provided to an emergency patient at an in-network or out-of-network facility.

Timely Filing Limitations:  Claims must be filed within 60 days after the date of service.

Payment by Payer:  A payer must pay the provider within 60 days of receiving the claim.

Reimbursement:  Claims that are subject to the Public Acts surprise billing protections must be paid by the payer at the greater of (1) the median amount negotiated by the patient’s carrier for the region and provider specialty, excluding any in-network coinsurance, copayments, or deductibles or (2)  150% of the Medicare fee for service fee schedule for the health care service provided, excluding any in-network coinsurance, copayments, or deductibles.

A provider may receive an additional 25% reimbursement who provides a health care service involving a complicating factor to an emergency patient.  Specific information must be submitted with the claim to demonstrate a complicating factor.

Disclosure – Notice and Consent:  A nonparticipating provider who provides care to a nonemergency patient must give a proper notice and obtain a consent to preserve their rights to balance bill the patient.  The disclosure must be issued at least 14 days before providing services or as soon as possible if services are scheduled less than 14 days in advance.

Prohibition of Disclosure: A disclosure cannot be issued to an emergency patient at the time of admittance to a hospital or when preparing the non-emergency patient for surgery or another medical procedure.

Disclosure Retention:  A signed disclosure must be retained by the provider for a minimum of 7 years.

What are the appeal rights if a provider disagrees with the payment amount?

When is arbitration available?

Contact Us to Understand How to Navigate the Surprise Billing Law

Rivet Health Law has been helping physicians understand the Michigan Surprise Billing Law since it was enacted, including the Federal No Surprise Act.  There are several factors to consider under both state and federal law.

We can assist with practice education, arbitration, negotiating claims, drafting policies, and notice and consents.