Date Held: March 12, 2021  
Location: Virtual Public Hearing through Microsoft Team Meetings  
Joe Kheder  
J. Rivet  
Julie Agueros  
Karin Gyger  
Kate (Guest)  
William Barnes  
Alison Porter  
Roger Smith  
Mollie Zito  
Aron Goldfeld, Team Health  
Nany Diapalski  
Renee Atkinson  
Bret Marr  
Alisyn Crawford  
Peggy Crandell  
Dr. Tony Bonfiglio  
Guest (no name)  
Belinda Chandler  
Tripp Vander Wal  
___________________________ (recording didn’t pick up opening of hearing). We will admit individuals as  
they enter the virtual hearing room. If you wish to speak, you must leave a comment in the Team’s Chat  
Box. If you’re calling into the meeting, and wish to speak, you will be given an opportunity to do so after  
anyone who has submitted a chat message has spoken. We will call on each individual who has entered a  
name in the chat box, in the order in which they have entered their request to speak. When it is your turn,  
please state and spell your name, indicate whether you are representing a particular organization, and  
state your address. If you are called on and do not wish to speak, simply let us know and we will move on  
to the next person. After all individuals who have submitted a chart box message have been called on, I will  
then ask whether there are any other individuals in attendance who wish to speak. This will include anyone  
whose attending by telephone or did not leave a name when entering the hearing.  
Finally, we will review any comments that were left in the chat function of the virtual hearing, and will enter  
them into the written record of public comments, and address anyone who may indicate a desire to speak.  
The purpose of this hearing is to receive public comments related to the proposed Rules. We will not be  
responding to any questions or comments. If you do have a question related to the proposed rules, please  
submit your questions, in writing, by email to Michele Estrada at E S T R A D A  
M, number 1 @ This email address is also listed on the Notice of Public Hearing, which is  
available on the department’s webpage. You may also email that same email address if you wish an email  
copy of the regulatory impact statement or the draft rules.  
Finally, you may also submit written comments, by emailing the same address no later than 5:00 p.m.  
(EST), today, March 12, 2021.  
Surprise Medical Billing Hearing  
March 12, 2021  
Page 2  
We will now begin calling on individuals who wish to speak by looking in the comment box. If you have any  
difficulty finding the comment box, please let me know, and I can direct you to it. So we will call on people  
in order in which they entered their name. So the first individual who wishes to speak is Tony Bonfiglio.  
Tony Bonfiglio: Thank you. Can everyone hear me okay? I’m very proud how this works out, I must say.  
Well thank you again for having me this morning.  
My name is Dr. Antonio Bonfiglio and I serve as the Chief Medical Officer at Ascension Macomb-Oakland  
Hospital in Warren, Michigan. I would like to first express my gratitude to Governor Whitmer, Director Fox,  
and their staff for working with our group on proposed rules guiding implementation of Michigan’s Surprise  
Medical Billing Act.  
I am a Board-Certified Emergency Doctor, currently still practicing in Southeast Michigan, and also am a  
Past-President of the Michigan College of Emergency Physicians. I am clinically employed by TeamHealth,  
which is a national hospital clinical staffing organization based in Knoxville, Tennessee. TeamHealth  
operates in 47 states, employing more than 15,000 clinicians across the country.  
In Michigan, TeamHealth employs more than 400 frontline workers, and operates at 12 hospital emergency  
departments primarily in Metro Detroit.  
In 2020, TeamHealth provided emergency care to nearly 375,000 patients, of which approximately 55,000  
were uninsured Michiganders.  
TeamHealth does not “Surprise Bill” patients. TeamHealth instead manages out-of-network billing issues  
directly with insurance carriers.  
I am here today to express reservations over the draft rules for the Act, in question, and respectfully  
request consideration of the modifications we delivered to the Department and attached to my written  
I, along with many of my colleagues, are concerned the proposed rules are alarmingly vague, likely leading  
to a rapid downward spiral in service reimbursements and correlated compensation made to frontline  
workers. The very same frontline workers that have been the backbone of the COVID pandemic in our  
state. This will ultimately impact the delivery of care throughout Michigan.  
We are convinced that without more developed rules, payers will systematically terminate managed care  
contracts to redefine the median “in network” rates moving forward and reduce overall payments to  
emergency medical providers.  
Some experts predict hospital emergency departments will see unsustainable reductions in  
reimbursements of 20% or more - leading to one of the following scenarios:  
Surprise Medical Billing Hearing  
March 12, 2021  
Page 3  
First: Hospitals will begin to subsidize emergency care to make up the corresponding reductions from  
insurance payments – which in many cases will be beyond the hospitals existing financial capabilities are.  
Second: Proportionate in cutbacks in manpower used to staff emergency departments. And/or,  
Third: Compensation reductions to frontline workers. Again, the same workers who bravely and steadfastly  
staffed ED’s across our State during this pandemic.  
Hospitals making up the difference is the least likely scenario, leaving reductions in staff levels and/or cuts  
in compensation our reality, this could lead to the following:  
First: Greater difficulty drawing skilled frontline workers to rural and urban areas; especially with indigent  
and low reimbursement populations, compounding already existing provider shortages.  
Second: Exacerbate pressures already on overworked staff, particularly alarming during the current COVID  
Third: Reduction in compensation for emergency physicians and frontline providers.  
Fourth: Increased waiting times in our emergency departments.  
Fifth: A likely reduction in the quality of care provided.  
Sixth: Increase in patient dissatisfaction.  
And finally, providers leaving our State.  
I am perplexed that the State has not anticipated these scenarios, and the impact the Act will have on  
emergency medicine without more clearly defined rules. Think about this a moment – a 20% reduction in  
compensation and increased workload thrust upon our very frontline caregivers during a pandemic. And  
this is over and above the already severe economic pressures shouldered in emergency departments since  
COVID began.  
To compound matters, as I mentioned, TeamHealth physicians provided care to 55,000 uninsured  
Michiganders annually, as mandated by law. Though we openly embrace this service as part of our  
mission, policymakers need to note, if paid, the average amount from this population is just 3 ½% of our  
breakeven cost - meaning we write off the balance 96 ½% as uncompensated services.  
Also, Medicaid payments for emergency providers is roughly 16% of our cost to deliver that care – forcing  
providers to absorb the balance 86% of this cost.  
Surprise Medical Billing Hearing  
March 12, 2021  
Page 4  
And though some uncompensated care cost is reimbursed through disproportionate share and low-income  
pool appropriations, these dollars are directed exclusively to brick and mortar hospitals, and not frontline  
providers and groups.  
And though emergency physicians currently treat roughly 5 of 10 uninsured and indigent patients, there are  
no programs that deliver us a comparable offset for our services.  
Presently, uncompensated care along with reimbursements from low payers like Medicaid and Medicare  
are offset and cross-subsidized by a range of in and out-of-network commercial payers, yielding our current  
economic market equilibrium in Michigan. But as noted, these amounts will quickly begin to drop by 20%, or  
so, unless the administration uses its authority to craft some guardrails moving forward.  
We believe implementing rules as we submitted are within the administration’s authority and spirit of the  
Michigan Surprise Billing Act. Nothing within our proposed rule amendments is prohibited by the Act, in  
fact, encouraged, as demonstrated by statements of “including, but not limited to…” Specifically, Public Act  
234, of 2020, allows the department to promulgate rules for two sections addressing the following:  
First: Median in-network rates, and  
Second: Complicating factors.  
Moreover, our proposed changes are equitable, and will help Michigan avoid undesirable and chaotic  
outcomes for emergency care, while maintaining the level of services and sustaining the medical safety-net  
Michiganders rely upon.  
In closing, my focus is to deliver care to my patients. However, the vagueness of this Administration’s  
Proposed Rules is alarming, and will likely lead to a downward spiral in emergency care. As an industry, we  
are respectively asking the Whitmer Administration to find the way to modify your rules, and to include more  
clear procedures containing, centering, excuse me, centering on median amounts and complicating factors,  
like those we have provided here today.  
Thank you very much.  
Sarah Wohlford: Thank you. Belinda Chandler, are you indicting a desire to submit a public comment?  
Belinda Chandler: Yes, I am.  
Sarah Wohlford: Ok, please proceed. Thank you.  
Belinda Chandler: Good morning everyone. My name is Belinda Chandler, and I am the Executive Director  
of the Michigan College of Emergency Physicians. I would also like to thank the Whitmer administration,  
Surprise Medical Billing Hearing  
March 12, 2021  
Page 5  
Department Director Anita Fox, and her staff for allowing me to present today. I am also happy to follow our  
past president, Dr. Antonio Bonfiglio.  
The Michigan College of Emergency Physicians has over 2,000 members and we have been before this  
committee on behalf of our members regarding surprise billing. We would like to continue the conversation  
regarding the proposed rules guiding implementation of Michigan’s Surprise Billing Act.  
During the legislative process, we stressed how this bill would create a significant financial burden for many  
emergency departments, particularly in the rural area, and ultimately limit access to care.  
We also stressed that Medicare is not an appropriate benchmark for determining out-of-network payments,  
since the Medicare program was established for the purpose of reimbursing medical services for an age-  
specific population, and, as such, rates do not appropriately reflect key underage-65 health services.  
Additionally, a federal bill was simultaneously being discussed as Michigan continued to move forward  
House Bill 4459 and 4460 for a vote.  
Now with the passing of the federal law, Michiganders will face dual arbitration systems with conflicting  
requirements. All ERISA plans will be handled by the federal system wile non-ERISA plans will be handled  
in Michigan. Discrepancies between these laws will only lead to confusion over what arbitration system will  
be used. Hospital emergency department will be at risk for reductions in their manpower as they are forced  
to subsidize the reduction in insurance payments.  
The Michigan College of Emergency Physicians is requesting that instead of two costly and confusing  
processes, consideration be given to allowing the federal law to take precedence and give our Michigan  
patients continuity in the arbitration process. Not doing so only achieves different payments, coverage, and  
chaos in navigating the varying array of requirements for resolving disputes.  
Thank you so much for giving your time.  
Sarah Wohlford: Thank you very much. I don’t see any other messages in the chat. So, I will open it up, if  
you want to raise your hand, or put a message in the chat, I want to be sure everybody who wants to speak  
has an opportunity to do so.  
Short moment of silence.  
May give it just a few more moments of silence to ensure everybody can navigate Teams appropriately and  
speak if they want to.  
If you would like to speak and cannot locate the chat or can’t raise your hand, you are welcome to unmute  
yourself and go ahead and state your name and provide your comment.  
Surprise Medical Billing Hearing  
March 12, 2021  
Page 6  
I will leave the floor open for a couple of more minutes to ensure that everybody who wants to speak has  
an opportunity to do so. Thank you.  
Ok. If there are no further comments, we will close the hearing. Any additional comments regarding the  
proposed rules must be submitted, in writing, by email to or by regular mail to  
the Department’s address listed on the Notice of Public Hearing, no later than 5:00 p.m. today, March 12,  
2021. Thank you for attending. The hearing is closed as of 10:16 a.m.  
Thank you.