Week in Review
New Michigan Law Regarding Prior Authorization Takes Effect June 1st
Process Designed to Be Quicker, More Effective, and Transparent
By: Stephanie Davidson
MAC Insurance Relations Manager
In April 2022, legislation promising prior authorization (PA) reform was signed into law by Governor Whitmer. The goal of the new law (Public Act 60 of 2022) is making the PA process faster, more effective, and transparent. It includes a standardized electronic prior authorization request transaction process, a requirement that prior authorization requirements be based on peer-reviewed clinical review criteria that meet certain requirements, and expedited review timelines. The new law is fully effective as of June 1, 2023.
It should be noted that in no way does Public Act 60 repeal prior authorization.
Among other provisions, the new law:
- Requires insurers that require a prior authorization with respect to any benefit to make available, by June 1, 2023, a standardized electronic prior authorization request transaction process.
- Requires prior authorization requirements to be based on peer-reviewed clinical review criteria that meet certain requirements.
- Requires insurers to post on their website if they implement a new prior authorization requirement or restriction – or amends an existing requirement or restriction – with respect to any benefit under a health benefit plan.
- Requires an adverse determination regarding a request for a prior authorization for a benefit other than a prescription drug benefit to be made by a licensed physician.
- Requires an insurer or its designee utilization review organization to notify, on issuing a medical benefit denial, the health professional and insured or enrollee of certain information, including the right to appeal the adverse determination, and require an appeal of the denial to be reviewed by a health professional to which certain requirements apply.
- Prohibits an insurer or its designee utilization review organization from affirming the denial of an appeal unless the appeal is reviewed by a licensed physician who meets certain qualifications.
- Prescribes procedures for granting a prior authorization request that has or has not been certified as urgent by a health care provider.
- Requires insurers to adopt a program that promotes the modification of prior authorization requirements of certain prescription drugs, medical care, or related benefits, based on certain factors.
Timeline: Urgent Vs. Non-Urgent Prior Authorization Requests
Under the new law, “urgent” means “an insured or enrollee is suffering from a health condition that may seriously jeopardize the insured’s life, health, or ability to regain maximum function or could subject the insured or enrollee to severe adverse health consequences that cannot be adequately managed without the care or treatment that is the subject of the prior authorization.” Beginning June 1, 2023, and moving forward, these PA requests must be acted upon within 72 hours, or they are considered granted.
For non-urgent prior authorization requests:
- June 1, 2023, through May 1, 2024: Request must be acted upon within nine (9) calendar days. If the insurer fails to act within this time frame, the request is considered granted.
- After May 1, 2024: The time frame shifts to seven (7) calendar days for non-urgent requests.
The decision is good for a minimum of 60 days, or the length of time that’s “clinically appropriate,” whichever is longer.
Please note: If the insurer (or its designated utilization review organization) requests additional information, be sure to provide it as quickly as possible, as the above turnaround times reset and the insurer will be required to make its determination following the receipt of the requested information within the above timelines.
Electronic Submissions
Beginning June 1, 2023, all requests for prior authorization must be submitted electronically, “unless the health professional is unable to use the standard process because of a temporary technological or electrical failure.”
“Peer-Reviewed Clinical Review Criteria”
All PA requirements must be based on “peer-reviewed clinical review criteria” that must do all of the following:
- Take into account the needs of atypical patient populations and diagnoses.
- Reflect community standards of care.
- Ensure quality of care and access to needed health care services.
- Be evidence-based criteria.
- Be publicly available free of charge.
- Be sufficiently flexible to allow deviations from norms when justified on a case-by-case basis.
- Be evaluated and updated, if necessary, at least annually.
Adverse Determinations
For an adverse determination regarding a request for prior authorization for a benefit other
than a prescription drug, the adverse determination must be made by a licensed physician. If the PA request is denied, the insurer must notify the health professional and insured or enrollee of the reasons for the denial and related evidence-based criteria, the right to appeal the adverse determination, instructions on how to file the appeal, and additional documentation necessary to support the appeal.
Appeals must be reviewed by a health professional who does not have a direct stake or any financial interest in the outcome of the appeal, has not been involved in making the adverse determination, and considers all known clinical aspects of the health care services under review (including a review of all pertinent medical records provided to the insurer or designee utilization review organization by the insured or enrollee's health care provider and any relevant records provided to the insurer or designee utilization review organization by a health care facility).
It should be noted that the reviewing health professional can – but is not required to – consider input from a health professional who is licensed in the same profession as the health professional providing the health care service.
Insurers are not allowed to affirm the denial of an appeal “unless the appeal is reviewed by a licensed physician who is board certified or eligible in the same specialty as a health care provider who typically manages the medical condition or disease or provides the health care service.” However, if an insurer or its designee utilization review organization cannot identify a licensed physician who meets the requirements described above without exceeding the applicable time limits imposed under the bill, the insurer or its designee review organization may utilize a licensed physician in a similar general specialty as considered appropriate, as determined by the insurer or its designee utilization review organization.
Additional Information
- Text of Public Act 60 of 2022
- Senate Fiscal Agency Analysis of Senate Bill 247 (as enacted)
Disclaimer: This article is meant to be information only, is not all-inclusive, and does not constitute legal advice regarding any specific matter or situation. Legal information is not the same as legal advice, which is the application of law to an individual’s specific matter, situation, or circumstances. Legal advice may be given only on the basis of specific facts relayed by a client to an attorney. The MAC goes to great lengths to make sure our information is as accurate, useful, and up to date as possible. We recommend, however, that you consult an attorney if you want or need professional assurance that our information, and your interpretation of it, applies to your specific legal situation.
Meridian Medicaid: New Prior Authorization Requirements Beginning July 1st
Prior Authorization Needed for Chiropractic Services Exceeding 18 Visits or More
Effective July 1, 2023, Meridian Medicaid will require prior authorizations for specific medically necessary chiropractic services (CPT codes 98940, 98941, and 98942) exceeding 18 visits. Prior authorization should be requested before performing any spinal manipulation that exceeds the 18-visit limit.
Please note: The initial 18 visits will not require prior authorization.
Prior authorization can be obtained on Meridian’s website: www.mimeridian.com > For Providers > Pre-Auth Check > Medicaid.
COA: Insurance Code Does Not Require Administrative Appeal as a Precondition to Sue Insurance Company Over Utilization Reviews
Published Opinion Holds That Appeals to DIFS Prior to Filing a Lawsuit is Wholly Discretionary
“Because the plain language of the operative statutes and regulations permit an administrative appeal rather than require it, [plaintiff] was not required to appeal the utilization review decision to the DIFS to satisfy administrative exhaustion requirements…”
- Michigan Court of Appeals
On May 25, 2023, the Michigan Court of Appeals issued a decision in True Care Physical Therapy v. Auto Club Group Insurance Company (COA Docket No. 362094), an auto no-fault case that involved a health care provider who filed suit against an auto insurance company rather than first appeal the insurer’s utilization review determination to the Michigan Department of Insurance and Financial Services (DIFS). According to the COA, Michigan’s revised auto no-fault insurance statute does not require a medical provider to administratively appeal an insurance company's utilization review. Rather, the administrative appeal process is optional, and providers may instead file suit without an appeal to DIFS.
The Initial Case
In the case, a 2018 auto accident victim suffered multiple injuries to her neck, back, and right shoulder and began a period of physical therapy with the plaintiff that lasted approximately two years. In 2021, the defendant stopped paying for treatment, following their utilization review. Defendant’s utilization review concluded that plaintiff’s treatment exceeded the American College of Occupational and Environmental Medicine (ACOEM) guidelines’ recommendations for the frequency and duration of treatment for injuries like the plaintiff’s patient. They then issued an explanation of benefits (EOB) denying plaintiff payment based on its utilization review.
Rather than appeal defendant’s determination to the Michigan Department of Insurance and Financial Services (DIFS), plaintiff filed a complaint in circuit court claiming that the defendant breached its contractual obligation to provide no-fault insurance benefits by refusing to pay for reasonable and necessary medical services that the plaintiff provided to the patient covered by the defendant.
Defendant moved for summary disposition on the basis that Michigan law (MCL 500.3157a) and The Administrative Rule governing utilization review (Rule 500.65) required plaintiff to appeal to DIFS before filing suit.
Plaintiff responded, arguing that it had a valid enforceable assignment of PIP benefits from their patient and that MCL 500.3112 of the no-fault act explicitly granted it the right to pursue a direct cause of action against the insurer in the trial court. An administrative appeal to DIFS was not mandatory, they insisted, and that if it were, that rule would conflict with other provisions of the no-fault act.
Without a hearing, the trial court issued an opinion and order denying the motion for summary disposition, ruling that MCL 500.3112 specifically granted plaintiff a direct and independent statutory cause of action against the defendant, and that the cause of action was without preconditions (they were not required to appeal to DIFS first).
The COA Opinion
A published opinion released Friday, May 26, 2023, written by Judge Noah Hood, joined by Judge Elizabeth Gleicher and Judge Allie Greenleaf Maldonado, affirmed the Oakland Circuit Court's denial of summary disposition filed by the defendant, stating:
"The trial court correctly denied [defendant’s] motion for summary disposition because it had subject-matter jurisdiction over [plaintiff’s] claim. At its core, a utilization review is an 'initial evaluation' of the appropriateness of the level and quality of treatment. The cause of action that the Legislature provided in MCL 500.3112 is not preconditioned on the permissive administrative appeal of that initial evaluation. The plain language of the no-fault act demonstrates that the Legislature intended alternate pathways for determining whether care was appropriate."
In the opinion’s conclusion, the Court writes:
“The trial court concluded that the no-fault act, MCL 500.3101 et seq., did not require True Care to administratively appeal Auto Club’s utilization review through the procedures in MCL 500.3157a and Mich Admin Code, R 500.65. We agree and affirm.”
It is not known at this time if the defendant will appeal the COA ruling to the Michigan Supreme Court, Stay tuned for updates as they become available.
If you’d like more information on how this case could affect your auto no-fault reimbursements, please contact Tim or Carl at the MAC.
Sources
CPAN, “COA: Admin Appeals to Insurance Reviews Not Mandatory Before Lawsuit,” May 30, 2023
Text of Michigan Court of Appeals decision in True Care Physical Therapy v. Auto Club Group Insurance Company (COA Docket No. 362094)
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