HOUSE BILL NO. 4884
June 28, 2023, Introduced by Reps. Rogers, Breen, Steckloff, Koleszar, Puri, McFall, Brabec,
Brixie, Neeley, Phil Green, Grant, Pohutsky, Haadsma, Wozniak, Martus, Churches, Morse,
Weiss, Hood, Roth, Paiz, Hope, Wilson, Morgan, Farhat, Byrnes, Dievendorf, Tyrone Carter,
Arbit, MacDonell, Conlin, Skaggs, Coffia, Rheingans, Andrews, Snyder, Tsernoglou, Scott,
Glanville, Price, Martin, Hill, McKinney, Wegela, Hoskins, Miller, Stone, Liberati,
VanderWall, O'Neal, Aiyash, BeGole, Borton, Edwards, Young, Zorn and Meerman and
referred to the Committee on Insurance and Financial Services.
A bill to amend 1956 PA 218, entitled
"The insurance code of 1956,"
by amending section 3157a (MCL 500.3157a), as added by 2019 PA 21.
THE PEOPLE OF THE STATE OF MICHIGAN ENACT:
1 Sec. 3157a. (1) By rendering any treatment, products,
2 services, or accommodations to 1 or more injured persons for an
3 accidental bodily injury covered by personal protection insurance
4 under this chapter after July 1, 2020, a physician, hospital,
5 clinic, or other person is considered to have agreed to do both of
6 the following:
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1 (a) Submit necessary records and other information concerning
2 treatment, products, services, or accommodations provided for
3 utilization review under this section.
4 (b) Comply with any decision of the department if a provider
5 elects to pursue an appeal under this section.
6 (2) A physician, hospital, clinic, or other person or
7 institution that knowingly submits under this section false or
8 misleading records or other information to an insurer, the
9 association created under section 3104, or the department commits a
10 fraudulent insurance act under section 4503.
11 (3) The department shall promulgate rules under the
12 administrative procedures act of 1969, 1969 PA 306, MCL 24.201 to
13 24.328, to do both of the following:
14 (a) Establish criteria or standards for utilization review
15 that identify utilization of treatment, products, services, or
16 accommodations under this chapter above the usual range of
17 utilization for the treatment, products, services, or
18 accommodations based on medically generally accepted standards.
19 (b) Provide procedures related to utilization review,
20 including procedures for all of the following:
21 (i) Acquiring necessary records, medical bills, and other
22 information concerning the treatment, products, services, or
23 accommodations provided.
24 (ii) Allowing an insurer to request an explanation for and
25 requiring a physician, hospital, clinic, or other person to explain
26 the necessity or indication for treatment, products, services, or
27 accommodations provided.
28 (iii) Appealing determinations.
29 (4) If a physician, hospital, clinic, or other person provides
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1 treatment, products, services, or accommodations under this chapter
2 that are not usually associated with, are longer in duration than,
3 are more frequent than, or extend over a greater number of days
4 than the treatment, products, services, or accommodations usually
5 require for the diagnosis or condition for which the patient is
6 being treated based on generally accepted standards, the insurer or
7 the association created under section 3104 may require the
8 physician, hospital, clinic, or other person to explain the
9 necessity or indication for the treatment, products, services, or
10 accommodations in writing under the procedures provided under
11 subsection (3).
12 (5) If an insurer or the association created under section
13 3104 determines that a physician, hospital, clinic, or other person
14 overutilized or otherwise rendered or ordered inappropriate
15 treatment, products, services, or accommodations that were not
16 reasonably necessary under section 3107, or that the cost of the
17 treatment, products, services, or accommodations was inappropriate
18 not reasonable under section 3107 or otherwise in accordance with
19 this chapter, the physician, hospital, clinic, or other person may
20 appeal the determination to the department under the procedures
21 provided under subsection (3) not later than 1 year after the
22 physician, hospital, clinic, or other person received payment from
23 the insurer or the association created under section 3104. If a
24 physician, hospital, clinic, or other person appeals the
25 determination under this subsection, the insurer or the association
26 created under section 3104 must provide the department and the
27 physician, hospital, clinic, or other person the methodology used
28 to determine the payment or reimbursement made by the insurer or
29 association created under section 3104. The methodology provided
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1 under this subsection must provide any adjustment made to the
2 amount payable to the provider under Medicare on a form approved by
3 the director.
4 (6) As used in this section: , "utilization
5 (a) "Generally accepted standards" means standards or
6 guidelines that are generally relied on by medical professionals or
7 others rendering treatment to an injured person, including
8 generally accepted practice guidelines, evidence-based practice
9 guidelines, or any other guidelines developed by the federal
10 government or national or professional medical academics,
11 associations, boards, or societies. Generally accepted standards do
12 not include any set of standards or guidelines developed by
13 private, for-profit corporations for commercial gain.
14 (b) "Utilization review" means the initial evaluation by an
15 insurer or the association created under section 3104 of the
16 appropriateness in terms of both the level and the quality of
17 treatment, products, services, or accommodations provided under
18 this chapter based on medically generally accepted standards.
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Statutes affected:
House Introduced Bill: 500.3157