The first significant area of concern is found at Rule 61 Sub J, the definition for medically accepted
standards. We know that this Rule is to fluctuant the new statutory requirement found in Section
3157.A.3.a. We believe medically accepted standard in the statute refers to those practices that are
generally accepted in the medical community. The purposed rule as currently drafted instead defines
medically accepted standards to be set by “a competent authority”. In the experience of MBIPC members
and its patients, the patients that we serve, resort to a “authority” results in standards being set by
insurance oriented organizations and those with credentials that are less than transparent. We suggest the
approach instead reflect the practices in the medical community. Therefore, we recommend the Rule 61,
Sub J, be revised to read as follows:
“Medically accepted standards mean standards or criteria that are generally accepted by
practicing physicians for evaluating quantity or quality of medical care insuring that the
medical care is suitable for a particular person, condition, occasion, or place. This definition
will reflect a community standard rather than a supposed authority of unknown origin.”
The second area of concern can be found at Rule 66, and the issue of exclusive remedy. We note that the
changes in this rule, from the first published draft, to this second draft, most notably at Section 1, it now
says that providers may appeal, and, at Sub-Section 7, it states that a provider that files an appeal does
not waive its right to seek civil remedies as to those things not appealed. But there remains concern. In
order for Rule 66 to be consistent with Section 3112 and the direct right of action given to providers, we
believe Rule 66, Sub 7, should more broadly state four points. First, that a provider is not obligated to
resort to appeal under these rules. Second, a provider may choose to exercise its right to civil remedies.
Third, a provider that files an appeal with the Department under this rule, does not waive its right to seek
civil remedies. And, four, nothing in these rules limit an injury person’s right to pursue his or her civil
remedies to secure benefits under the no-fault act.
Those four brief statements, if stated at Rule 66, Sub 7, will alleviate any concern about exclusivity of
remedy. It will then be consistent with Section 3112 of the act.
The third area of concern is an issue in Rule 64 and 65. And generally stated, it is the lack of identified
deadlines imposed on insurers for response to providers. By way of example, at Rule 65, insurers are
instructed that certain information must be stated in their written determination notice to providers. We
thank you for that, however, lacking from the purposed rule is a period of time within which the
determination must be made by the insurer and given to the provider. Conversely, there are very clearly
stated deadlines placed on providers within these rules. In Rule 64, for an example, an insurer may request
from the provider a written explanation regarding the necessity or indication for medical care. At Rule 64,
Sub-Section 2, providers are told they must respond to that request, and they are told they must do so
within 60 days. Likewise providers are instructed at Rule 66 about the deadline to file an appeal. As
providers we appreciate deadlines of these kinds, but we note that opportunities to impose the same on
insurers have not been stated in these draft rules. To be clear, MBIPC seeks these rules impose on
insurers, much like providers, deadlines for insurer action to respond and issue determinations. Without
these kind of short time periods under which insurers must respond or make determinations, the usefulness
of a review of this kind for providers is undermine significantly.
In the final issue that I will touch on very briefly, is a concern to raise with you, regarding Rule 67.2.c. This
rule refers to independent medical examinations pursuant to Section 3151 of the No-Fault Law.