Utilization Review for Nurses, Physicians and Hospitals That Bill No-Fault Auto Insurance
Utilization review is the scrutiny that nurses, physicians, hospitals, clinics and medical providers who care for and treat car accident victims will have to undergo in order to be reimbursed for their services under the No-Fault auto insurance law. They will be required to justify how their services are utilized and charged for.
What is a utilization review?
Utilization review is the process by which an auto insurance company or the Michigan Catastrophic Claims Association evaluates whether the medical treatment or care, products, services or accommodations provided to car accident victims are “above the usual range of utilization . . . based on medical accepted standards” (i.e., whether they are appropriate “in terms of both the level and the quality”). (MCL 500.3157a(3)(a) and (6))
What is the utilization review looking for?
What insurers and the MCCA are looking for in the “utilization process” is whether the medical treatment and care, products, services and accommodations that doctors provide to car accident victims are:
- “[N]ot usually associated with, are longer in duration than, are more frequent than, or extend over a greater number of days than” is “usually” required;
- Overutilized or inappropriate; or
- Billed at “inappropriate” costs. (MCL 500.3157a(4) and (5))
Who is subject to the review?
After July 1, 2020, any doctor, hospital, clinic, or other person that seeks reimbursement through No-Fault auto insurance for providing medical treatment or care, products, services or accommodations to car accident victims must “[s]ubmit necessary records and other information” to the Michigan Insurance Commissioner for review. (MCL 500.3157a(1))
Any “proprietary information or sensitive personally identifiable information regarding a patient that is submitted” by doctors, hospitals, clinics or other persons to the Insurance Commissioner as part of the review process “is exempt from disclosure” under the Freedom of Information Act. (MCL 500.3157b)
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