Department of Insurance and Financial Services  
Proposed Rulemaking  
R 500.241, R 500.242, R 500.243, R 500.244, and R 500.245, Michigan  
Administrative Code  
Testimony By Antonio Bonfiglio, M.D.  
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 express my gratitude to Governor Whitmer, Director  
Anita 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 and Past-President of the  
Michigan College of Emergency Physicians. I am employed by  
TeamHealth, 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 this state during 2020, TeamHealth, provided emergency care to  
nearly 375,000 patients, of which approximately 55,000 were  
uninsured Michiganders.  
TeamHealth does not “Surprise Billpatience, but 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 and respectfully request consideration of the modifications we  
delivered to the Department and attached to my written testimony.  
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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. 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 physicians.  
Some experts predict hospital emergency departments will see  
unsustainable reductions in reimbursements of 20% or more -  
leading to one of the following scenarios:  
1. Hospitals will subsidize emergency care to make up the  
corresponding reductions from insurance payments which in  
many cases will be beyond the hospitals existing financial  
capabilities.  
2. Proportionate cutbacks in manpower used to staff emergency  
departments. And/or,  
3. Compensation reductions to frontline workers.  
Hospitals making up the difference is the least likely scenario, leaving  
reductions in staff levels and/or cuts in compensation our reality,  
leading to the following:  
1. Greater difficulty drawing skilled frontline workers to rural  
and urban areas; especially those with indigent and low  
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reimbursement populations, compounding already existing  
provider shortages.  
2. Exacerbate pressures already on overworked staff, which is  
particularly alarming during the current Covid-19 pandemic.  
3. Reduction in compensation for emergency physicians and  
frontline providers.  
4. Emergency providers leaving Michigan.  
5. Increased waiting times in emergency departments.  
6. Likely reduction in the delivery and quality of care.  
7. Increase in patient complaints.  
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-19 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 care forcing providers to absorb the balance  
86% of this cost.  
And though some uncompensated care cost is reimbursed through  
disproportionate share and low-income pool appropriations, these  
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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 like  
“including, but not limited to…” Specifically, Public Act 234, of 2020,  
allows the department to promulgate rules for two sections  
addressing:  
o Median in-network rates, and  
o Complicating factors.  
Moreover, our proposed changes are equitable, serving the public  
good by helping Michigan avoid undesirable and chaotic outcomes  
for emergency care, while maintaining the level of service and  
medical safety-net Michiganders rely upon.  
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In closing, my focus is delivering care to my patients, however, the  
vagueness of the Administration’s proposed rules is alarming and  
will likely lead to a downward spiral in emergency care. As an  
industry we are respectfully asking the Whitmer Administration to  
find the way to modify your rules, and to include more clear  
procedures centering on median amounts and complicating factors,  
like those we provided.  
Thank you  
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Testimony Antonio Bonfiglio - Supporting Documentation  
MEDIAN AMOUNT”  
Public Act 234 of 2020 does not contain a specific definition of  
“median amount.”  
Emergency providers view the proposed Rules as too vague, allowing  
payers to inappropriately ratchet down rates currently expected in  
the marketplace. This consequence has nothing to do with Surprise  
Medical billing as contemplated in the act, nor legislative intent.  
The main intent of the Act is to prevent “balanced billsissued to  
policyholders if service is given to an “out of network” patient.  
With the rules as drafted, we anticipate payers to begin suspending  
contracts with emergency providers, force renegotiations, and  
rachet down rates to our industry, at unsustainable levels. This was  
not the intent of Public Act 234 of 2020.  
Nothing prohibits the Department from establishing the base year as  
2019, and adjust moving forward using the Consumer Price Index,  
discounting 2020 as an outlier year in light of Covid-19.  
Tying the median amount to the CPI is also logical and not prohibited  
by the PA234’20. In fact, significant precedence is established using  
the CPI within and outside of government mandates.  
Section 24510, Subsection (2) grants the Department the authority  
to “consult an external database that contains the negotiated rates  
under the patient’s health benefit plan for the applicable health care  
service.” This language allows the Department to establish a  
generally accepted factfinder such as Fairhealth, for the “external  
database,” along with establishing a date in time as the benchmark  
period. This is only logical.  
Moreover, nothing prohibits the need to establish an unbiased  
source and create a starting point for the department, payers, and  
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providers to follow. Otherwise, chaos will ensue as detailed by my  
colleague in his earlier statement - which certainly cannot be the  
intent of PA 234’20 - particularly during a pandemic.  
In fact, using the last full year of provider/payer agreements sets the  
stage for steady market adjustments, with rules tied to nationally  
accepted metrics, such as the CPI.  
Including language that requires weighted averages is also not  
precluded by PA 234’20 and is designed to provide equity to the  
process of reimbursement for services delivered to patients.  
Proposed language within Rule 4, for instance is not mandated, but  
rather the establishment of logical requirements to carry out the  
intent of the Act.  
Following, we are requesting logical steps to prevent carriers from  
using rates from a lower paying region, to dilute the rate for higher  
paying areas of the state, and for the Department to codify this  
moving forward.  
And to limit the payment data to include only rates applicable to  
those controlled by this Act also stands to reason.  
And finally, requiring that the median amount calculations be based  
on a payer’s provider directory for services given by the  
nonparticipating provider is also not prohibited by PA 234’20 and  
instills logic and fairness when calculated median amounts.  
7
Testimony Antonio Bonfiglio - Supporting Documentation  
COMPLICATING FACTOR”  
Section 24511, subsection (8) of Public Act 234 of 2020 defines  
complicating factors and lays out three priorities, namely:  
o Increased intensity, time, or technical difficulty of the health  
care service.  
o The severity of the patient’s condition.  
o The physical or mental effort required in providing the health  
care service  
However, clearly, the statute is relying on the department to develop  
and expand the definition by including the term: “…including, but  
not limited to…”.  
To this, we are simply requesting the Rules include clearly delineated  
medical conditions by accepting generally accepted medical  
diagnosis and coding terminology tools.  
We also request a clear and generally standardized procedure, via  
form or otherwise, that affords a provider a mechanism to inform  
payers of a complicating factor when an “out-of-network” patient  
presents for emergency care, and next steps when a disagreement  
over reimbursement or complicating factors occurs.  
And we request a requirement that insured be noticed by the payer  
of plan benefits in accordance with the Act.  
We also ask for specific guidance as to the medical conditions and  
diagnoses the department deems sufficient to constitute  
complicating factors by using commonly accepted medical  
8
terminology and numerical coding methodologies (icd-10) as well as  
a method for identifying the presence of a complicating factor on the  
medical claim form submitted to the health plan for payment.  
And finally, we are requesting the Department establish and publish  
an annual list of accepted “complicating factors” for the industry to  
reference.  
Together, these modifications to the proposed rules are reasonable  
and necessary to help emergency providers deliver expected care,  
while maintaining market equilibrium for the industry.  
9
Department of Insurance and Financial Services Proposed Rulemaking  
R 500.241, R 500.242, R 500.243, R 500.244, and R 500.245, Michigan Administrative Code  
Personnel Testimony – By Belinda Chandler, CAE  
My name is Belinda Chandler, and I am the Executive Director of the Michigan College of  
Emergency Physicians and would like to thank the Whitmer administration, Department  
Director Anita Fox, and her staff for allowing me to present today. I am also happy to follow  
our past present, Dr. Antonio Bonfiglio.  
The Michigan College of Emergency Physician 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  
yet 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 while non-  
ERISA plans will be handled in Michigan. Discrepancies between these laws will only lead to  
confusion over what arbitration system will be used. Hospitals’ emergency departments 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.  
(Proposed Rule Modifications for Consideration TeamHealth 2-2-21)  
DEPARTMENT OF INSURANCE AND FINANCIAL SERVICES  
INSURANCE  
SURPRISE MEDICAL BILLING  
Filed with the secretary of state on  
These rules take effect immediately upon filing with the secretary of state unless adopted  
under section 33, 44, or 45a (6) of the administrative procedures act of 1969, 1969 PA 306,  
MCL 24.233, 24.244, or 24.245a. Rules adopted under these sections become effective 7  
days after filing with the secretary of state.  
(By authority conferred on the director of the department of insurance and financial services  
by section 24517 of the public health code, 1978 PA 368, MCL 333.24517)  
R 500.241, R 500.242, R 500.243, R 500.244, and R 500.245 are added to the Michigan  
Administrative Code as follows:  
R 500.241 Definitions.  
Rule 1. (1) As used in these rules:  
(a) “Act” means the public health code, 1978 PA 368, MCL 333.1101 to 333.25211.  
(b) “Median amount” means the median amount negotiated by the carrier for the region and  
provider specialty, excluding any in-network coinsurance, copayments, or deductibles. The  
carrier shall determine the region and provider specialty.  
(i) THE MEDIAN AMOUNT SHALL REFLECT THE ACTUAL AMOUNTS  
PAID TO CONTRACTED PROVIDERS IN THE YEAR [2019], KNOWN AS THE BASE  
YEAR.  
(ii) THE BASE YEAR SHALL BE ADJUSTED IN AN AMOUNT EQUAL TO  
THE CHANGE IN THE ANNUAL CONSUMER PRICE INDEX FOLLOWING THE  
URBAN (CPI-U) TO REFLECT THE MEDIAN AMOUNT IN THE CURRENT BENEFIT  
YEAR.  
(iii) THE MEDIAN AMOUNT SHALL BE REFLECTIVE OF PAYMENTS  
MADE SOLELY TO INDIVIDUALLY CONTRACTED PROVIDERS, EACH OF WHOM  
WERE CONTRACTED WITH THE CARRIER IN THE NONPARTICIPATING  
PROVIDER’S RECOGNIZED SPECIALTY DURING THE BASE YEAR.  
(iv) THE DEPARTMENT SHALL ENSURE THAT THE MEDIAN AMOUNT IS  
WEIGHTED IN A MANNER THAT BEST REPRESENTS THE FREQUENCY OF  
PAYMENTS ISSUED TO INDIVIDUALLY CONTRACTED PROVIDERS IN THE  
NONPARTICIPATING PROVIDER’S RECOGNIZED SPECIALTY DURING THE BASE  
YEAR.  
(v) THE MEDIAN AMOUNT SHALL NOT REFLECT PAYMENTS MADE TO  
CONTRACTED PROVIDERS OR PROVIDER GROUPS WHO WERE NOT LISTED IN  
2
THE CARRIER’S PROVIDER DIRECTORY UNDER THE SAME SPECIALTY AS THAT  
OF THE NONPARTICIPATING PROVIDER.  
(c) “COMPLICATING FACTOR’ MEANS:  
(i) A FACTOR THAT IS NOT NORMALLY INCIDENT TO A HEALTH CARE  
SERVICE, INCLUDING, BUT NOT LIMITED TO THE FOLLOWING:  
(a) INCREASED INTENSITY, TIME, OR TECHNICAL DIFFICULTY  
OF THE HEALTH CARE SERVICE;  
(b) THE SEVERITY OF THE PATIENT’S CONDITION; AND,  
(c) THE PHYSICAL OR MENTAL EFFORT REQUIRED IN  
PROVIDING THE HEALTH CARE SERVICE.  
(ii) THE DEPARTMENT SHALL DELINEATE MEDICAL CONDITIONS THAT  
CONSTITUTE ‘COMPLICATING FACTORS’ BY UTILIZING GENERALLY  
ACCEPTED MEDICAL DIAGNOSIS AND CODING TERMINOLOGY TOOLS AND  
RESOURCES DETERMINED BY THE INTERNATIONAL CLASSIFICATION OF  
DISEASE, TENTH EDITION (ICD-10), AND THE AMERICAN MEDICAL  
ASSOCIATION’S COMMON PROCEDURE TERMINOLOGY (CPT) WITH BOTH  
SERVING AS RECOGNIZED RESOURCES FOR CARRYING OUT THE ACT, IN  
ACCORDANCE WITH R500.245(1).  
(2) THE DEPARTMENT SHALL INSTRUCT CARRIER’S TO IDENTIFY A  
METHOD BY WHICH A NONPARTICIPATING PROVIDER MAY INDICATE THE  
PRESENCE OF A ‘COMPLICATING FACTOR’ ON THE CLAIM SUBMISSION FORM  
WHETHER FILED ELECTRONICALLY OR ON PAPER, WHICH SHALL BE DEEMED  
SUFFICIENT FOR THE CARRIER TO RECOGNIZE, PROCESS AND ISSUE A  
SUPPLEMENTAL OUT-OF-NETWORK PAYMENT IN ACCORDANCE WITH THIS  
ACT.  
THE DEPARTMENT SHALL REQUIRE THE CARRIER TO NOTICE THE  
NONPARTICIPATING PROVIDER AS PART OF THE CARRIER’S EXPLANATION OF  
BENEFITS, EITHER ELECTRONICALLY OR IN PAPER FORM, THAT THE MEDIAN  
AMOUNT PAYMENT ISSUED INCLUDES A SUPPLEMENTAL COMPLICATING  
FACTORPAYMENT AT THE STIPULATED ADD-ON PAYMENT PERCENTAGE  
INCREASE REQUIRED BY THIS ACT.  
THE CARRIER MAY ALSO CHOOSE TO DENY THE NONPARTICIPATING  
PROVIDER’S CLAIM FOR A SUPPLEMENTAL ‘COMPLICATING FACTOR’  
PAYMENT BUT MUST NOTIFY THE NONPARTICIPATING PROVIDER BY  
COMMUNICATING ANY DENIAL ON ITS EXPLANATION OF BENEFITS FORM,  
EITHER ELECTRONICALLY OR ON PAPER, AND IN DOING SO, ADVISE THE NON-  
PARTICIPATING PROVIDER THAT HE OR SHE MAY CHOOSE TO APPEAL THE  
CARRIER’S DETERMINATION BY COMMUNICATING WITH THE DEPARTMENT  
ON A FORM SPECIFIED BY THE DEPARTMENT AND BY ACCESSING THE  
ARBITRATION PROVISIONS MADE AVAILABLE BY THE DEPARTMENT.  
(3) THE DEPARTMENT SHALL REQUIRE THE CARRIER TO IDENTIFY ON  
ALL MEMBER INSURANCE IDENTIFICATION CARDS AND EXPLANATION OF  
TH/AF/JK 2-2-21  
3
BENEFITS, EITHER ELECTRONICALLY OR ON PAPER, PLAN BENEFITS TO BE  
ADMINISTERED, PAID OR DENIED IN ACCORDANCE WITH THIS ACT.  
(4) THE DEPARTMENT SHALL ESTABLISH AND PUBLISH A SCHEDULE  
OR LIST, WHICH SHALL BE UPDATED ANNUALLY DELINEATING MEDICAL  
SERVICES AND CONDITIONS THE DEPARTMENT DEEMS MEET THE DEFINITION  
OF A ‘COMPLICATING FACTOR’.  
THE SCHEDULE THE DEPARTMENT PUBLISHES SHALL BE CROSS-  
REFERENCED TO GENERALLY ACCEPTED MEDICAL DOCUMENTATION TOOLS  
AND RESOURCES IN ACCORDANCE WITH 500.241, SUBSECTION (1)(C) OF THE  
ACT, MCL 333.24511.  
(5) A term defined in the act for the purposes of article 18 of the act, MCL 333.24501  
to 333.24517, has the same meaning when used in these rules.  
R 500.242 Scope and applicability.  
Rule 2. These rules do the following:  
(a) Establish procedures for the department to review and resolve requests for calculation  
review OF THE MEDIAN AMOUNT submitted pursuant to section 24510 of the act, MCL  
333.24510.  
(b) Establish procedures for approving arbitrators to provide binding arbitration pursuant to  
section 24511 of the act, MCL 333.24511.  
R 500.243 Requests for calculation review.  
Rule 3. (1) A nonparticipating provider must make a request for calculation review on a  
form provided by the department.  
(2) In response to a request from a nonparticipating provider for a calculation review  
under section 24510 of the act, MCL 333.24510, the department shall do the following within  
14 days of the date of the request:  
(a) Notify the carrier of the request for a calculation review.  
(b) Request data on the carrier’s median amount or any documents, materials, or other  
information the department believes is necessary to assist in reviewing the request for  
calculation review.  
(c) CONSULT OR REQUEST SUPPORTING INFORMATION FROM A NATIONALLY  
RECOGNIZED PHYSICIAN ALLOWABLE DATABASE IN ACCORDANCE WITH  
R500.244(2).  
(3) A carrier must respond within 7 days of the date of the department’s request  
under subrule (2)(b) of this rule. If the information provided is incomplete, the department  
may, at its discretion, request additional information, or issue a determination based solely on  
the information provided as of the date on which the carrier’s response was due. If the  
department makes 1 or more requests for additional information, the department shall extend  
the time period permitted for the carrier’s response for a number of days the department  
considers appropriate.  
(4) The department shall issue a determination resolving the request for a calculation  
review no later than 14 days after the carrier submits a timely and complete response under  
TH/AF/JK 2-2-21  
4
subrule (3) of this rule or after the expiration of the time period within which the carrier was  
required to respond, including any extensions provided under subrule (3) of this rule.  
R 500.244 Median amount; access to database.  
Rule 4. (1) Subject to subrule (3) of this rule, a carrier may satisfy the requirement under R  
500.243 by providing the department with access to a database that contains all of the carrier’s  
median amounts. The database must meet all of the following requirements:  
(a) Be updated no less frequently than quarterly.  
(b) Be searchable by region, provider specialty, and health care service.  
(c) Include negotiated rates for all health care services covered by the carrier,  
GEOGRAPHICALLY ADJUSTED AND IF APPLICABLE, ISOLATED BY PLAN  
PRODUCT TYPE SO NOT TO BLEND OR MERGE VARYING CONTRACT RATE  
STRUCTURES FOR THE PURPOSES OF ARTIFICIALLY ADJUSTING THE MEDAIN.  
THIS SHALL BE FURTHER LIMITED TO PROVIDERS REPORTED IN THE  
CARRIER’S CURRENTLY PUBLISHED PROVIDER DIRECTORY, SORTED FOR  
EACH GIVEN SPECIALTY;  
(d) REPRESENT CONTRACTED PAYMENT RATES FOR COMMERCIAL HEALTH  
BENEFIT PLANS ONLY, THAT ARE REGULATED BY THE DEPARTMENT, AND  
WHICH. SHALL NOT INCLUDE PROVIDER CONTRACT RATES ASSOCIATED  
WITH BENEFIT PLANS THE CARRIER ADMINISTERS ON BEHALF OF MEDICARE,  
MEDICAID OR OTHER GOVERNMENT HEALTH BENEFIT PROGRAMS.  
(e) Be continuously accessible to the department.  
(2) For the purposes of conducting a calculation review under section 24510 of the  
act, MCL 333.24510, the department may, at its discretion, consult any external database  
described under section 24510(2) of the act, MCL 333.24510, without regard to whether a  
carrier made the database accessible to the department or whether the database otherwise  
meets the requirements under subrule (1) of this rule.  
SUCH  
DATABASE  
SHALL  
BE  
NATIONALLY  
RECOGNIZED,  
GEOGRAPHICALLY ADJUSTED AND SPECIALTY SPECIFIC, SORTED BY  
GEOGRAPHIC ALLOWABLE PAYMENT PERCENTILES, PROCURED BY A NOT-  
FOR-PROFIT ENTITY, WHICH IS NOT AFFILIATED, EITHER DIRECTLY OR  
INDIRECTLY, WITH AN INSURANCE CARRIER OR HEALTH. BENEFIT PLAN.  
(3) A carrier’s provision of access to a database under this rule does not preclude  
the department from requesting additional documents, materials, or other information that the  
department determines is necessary for conducting a review under section 24510 of the act,  
MCL 333.24510.  
R 500.245 Approval of arbitrators.  
Rule 5. (1) The department shall create and maintain a list of arbitrators trained by the  
American Arbitration Association or American Health Lawyers Association WHO POSSESS  
KNOWLEDGE OF MEDICAL REIMBURSEMENT AND EXPERIENCE IN THE USE OF  
MEDICAL TERMINOLOGY AND MEDICAL CODING, INCLUDING BUT NOT  
LIMITED TO THE INTERNATIONAL CLASSIFICATION OF DISEASE, TENTH  
EDITION (ICD-10), AND THE AMERICAN MEDICAL ASSOCIATION’S COMMON  
PROCEDURE TERMINOLOGY (CPT) AND WHO SHALL BE approved by the director.  
TH/AF/JK 2-2-21  
5
This list must be updated no less frequently than annually and must be posted on the  
department’s website.  
THE ARBITRATOR AND DEPARTMENT MAY CHOOSE TO SEEK THE  
ASSISTANCE OF MEDICAL PROFESSIONALS LICENSED IN THE STATE OF  
MICHIGAN AND TRAINED IN THE MEDICAL SPECIALITY IN THE DISPUTE IN  
QUESTION FOR THE PURPOSE OF ASSISTING THE ARBITRATOR RULE ON THE  
PRESENCE OF OR LACK THEREOF OF A COMPLICATING FACTOR.  
THE SELECTED MEDICAL PROFESSIONAL SHALL HAVE NO  
AFFILIATION OR RELATIONSHIP WITH EITHER OF THE PARTIES.  
(2) Arbitrators seeking to be included in the list under subrule (1) of this rule must  
apply on a form prescribed by the department.  
(3) The department shall approve or disapprove an application no later than 60 days  
after the date of receipt of the application. Applicants whose application has been disapproved  
may reapply at any time.  
(4) If approved for inclusion in the list under subrule (1) of this rule, arbitrators  
must annually provide to the department, on a form prescribed by the department, an  
attestation acknowledging that the information provided to the department in the arbitrator’s  
application under subrule (2) of this rule remains complete and accurate.  
(5) Arbitrators included on the department’s list under subrule (1) of this rule must  
notify the department of any changes to the information contained in the arbitrator’s  
application under subrule (2) of this rule within 30 days of the change. An arbitrator’s failure  
to inform the department of these changes may result in revocation of the arbitrator’s approval  
and removal from the list under subrule (1) of this rule.  
TH/AF/JK 2-2-21  
Department of Insurance and Financial Services  
Proposed Rulemaking  
R 500.241, R 500.242, R 500.243, R 500.244, and R 500.245, Michigan  
Administrative Code  
Testimony By Antonio Bonfiglio, M.D.  
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 express my gratitude to Governor Whitmer, Director  
Anita 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 and Past-President of the  
Michigan College of Emergency Physicians. I am employed by  
TeamHealth, 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 this state during 2020, TeamHealth, provided emergency care to  
nearly 375,000 patients, of which approximately 55,000 were  
uninsured Michiganders.  
TeamHealth does not “Surprise Billpatience, but 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 and respectfully request consideration of the modifications we  
delivered to the Department and attached to my written testimony.  
1
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. 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 physicians.  
Some experts predict hospital emergency departments will see  
unsustainable reductions in reimbursements of 20% or more -  
leading to one of the following scenarios:  
1. Hospitals will subsidize emergency care to make up the  
corresponding reductions from insurance payments which in  
many cases will be beyond the hospitals existing financial  
capabilities.  
2. Proportionate cutbacks in manpower used to staff emergency  
departments. And/or,  
3. Compensation reductions to frontline workers.  
Hospitals making up the difference is the least likely scenario, leaving  
reductions in staff levels and/or cuts in compensation our reality,  
leading to the following:  
1. Greater difficulty drawing skilled frontline workers to rural  
and urban areas; especially those with indigent and low  
2
reimbursement populations, compounding already existing  
provider shortages.  
2. Exacerbate pressures already on overworked staff, which is  
particularly alarming during the current Covid-19 pandemic.  
3. Reduction in compensation for emergency physicians and  
frontline providers.  
4. Emergency providers leaving Michigan.  
5. Increased waiting times in emergency departments.  
6. Likely reduction in the delivery and quality of care.  
7. Increase in patient complaints.  
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-19 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 care forcing providers to absorb the balance  
86% of this cost.  
And though some uncompensated care cost is reimbursed through  
disproportionate share and low-income pool appropriations, these  
3
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 like  
“including, but not limited to…” Specifically, Public Act 234, of 2020,  
allows the department to promulgate rules for two sections  
addressing:  
o Median in-network rates, and  
o Complicating factors.  
Moreover, our proposed changes are equitable, serving the public  
good by helping Michigan avoid undesirable and chaotic outcomes  
for emergency care, while maintaining the level of service and  
medical safety-net Michiganders rely upon.  
4
In closing, my focus is delivering care to my patients, however, the  
vagueness of the Administration’s proposed rules is alarming and  
will likely lead to a downward spiral in emergency care. As an  
industry we are respectfully asking the Whitmer Administration to  
find the way to modify your rules, and to include more clear  
procedures centering on median amounts and complicating factors,  
like those we provided.  
Thank you  
5
Testimony Antonio Bonfiglio - Supporting Documentation  
MEDIAN AMOUNT”  
Public Act 234 of 2020 does not contain a specific definition of  
“median amount.”  
Emergency providers view the proposed Rules as too vague, allowing  
payers to inappropriately ratchet down rates currently expected in  
the marketplace. This consequence has nothing to do with Surprise  
Medical billing as contemplated in the act, nor legislative intent.  
The main intent of the Act is to prevent “balanced billsissued to  
policyholders if service is given to an “out of network” patient.  
With the rules as drafted, we anticipate payers to begin suspending  
contracts with emergency providers, force renegotiations, and  
rachet down rates to our industry, at unsustainable levels. This was  
not the intent of Public Act 234 of 2020.  
Nothing prohibits the Department from establishing the base year as  
2019, and adjust moving forward using the Consumer Price Index,  
discounting 2020 as an outlier year in light of Covid-19.  
Tying the median amount to the CPI is also logical and not prohibited  
by the PA234’20. In fact, significant precedence is established using  
the CPI within and outside of government mandates.  
Section 24510, Subsection (2) grants the Department the authority  
to “consult an external database that contains the negotiated rates  
under the patient’s health benefit plan for the applicable health care  
service.” This language allows the Department to establish a  
generally accepted factfinder such as Fairhealth, for the “external  
database,” along with establishing a date in time as the benchmark  
period. This is only logical.  
Moreover, nothing prohibits the need to establish an unbiased  
source and create a starting point for the department, payers, and  
6
providers to follow. Otherwise, chaos will ensue as detailed by my  
colleague in his earlier statement - which certainly cannot be the  
intent of PA 234’20 - particularly during a pandemic.  
In fact, using the last full year of provider/payer agreements sets the  
stage for steady market adjustments, with rules tied to nationally  
accepted metrics, such as the CPI.  
Including language that requires weighted averages is also not  
precluded by PA 234’20 and is designed to provide equity to the  
process of reimbursement for services delivered to patients.  
Proposed language within Rule 4, for instance is not mandated, but  
rather the establishment of logical requirements to carry out the  
intent of the Act.  
Following, we are requesting logical steps to prevent carriers from  
using rates from a lower paying region, to dilute the rate for higher  
paying areas of the state, and for the Department to codify this  
moving forward.  
And to limit the payment data to include only rates applicable to  
those controlled by this Act also stands to reason.  
And finally, requiring that the median amount calculations be based  
on a payer’s provider directory for services given by the  
nonparticipating provider is also not prohibited by PA 234’20 and  
instills logic and fairness when calculated median amounts.  
7
Testimony Antonio Bonfiglio - Supporting Documentation  
COMPLICATING FACTOR”  
Section 24511, subsection (8) of Public Act 234 of 2020 defines  
complicating factors and lays out three priorities, namely:  
o Increased intensity, time, or technical difficulty of the health  
care service.  
o The severity of the patient’s condition.  
o The physical or mental effort required in providing the health  
care service  
However, clearly, the statute is relying on the department to develop  
and expand the definition by including the term: “…including, but  
not limited to…”.  
To this, we are simply requesting the Rules include clearly delineated  
medical conditions by accepting generally accepted medical  
diagnosis and coding terminology tools.  
We also request a clear and generally standardized procedure, via  
form or otherwise, that affords a provider a mechanism to inform  
payers of a complicating factor when an “out-of-network” patient  
presents for emergency care, and next steps when a disagreement  
over reimbursement or complicating factors occurs.  
And we request a requirement that insured be noticed by the payer  
of plan benefits in accordance with the Act.  
We also ask for specific guidance as to the medical conditions and  
diagnoses the department deems sufficient to constitute  
complicating factors by using commonly accepted medical  
8
terminology and numerical coding methodologies (icd-10) as well as  
a method for identifying the presence of a complicating factor on the  
medical claim form submitted to the health plan for payment.  
And finally, we are requesting the Department establish and publish  
an annual list of accepted “complicating factors” for the industry to  
reference.  
Together, these modifications to the proposed rules are reasonable  
and necessary to help emergency providers deliver expected care,  
while maintaining market equilibrium for the industry.  
9
March 11, 2021  
To: Department of Insurance and Financial Services  
RE: Surprise Billing Draft Rules  
Via Email to: Michele Estrada: estradam1@michigan.gov  
MAHP Commentary on Proposed  
Surprise Medical Billing Rules  
To Whom It May Concern:  
The Michigan Association of Health Plans (MAHP) represents ten health insurers licensed in the  
State of Michigan who insure over 3.1 million Michiganders in various lines of business. Our  
work is focused on providing Michiganders with high-quality, competitive, and affordable  
health insurance that improves their quality of life. The Surprise Medical Billing Legislation  
accomplishes all of MAHPs stated goals.  
Representative Hauck, the Chief Sponsor of the bill package, stated the Surprise Billing Package  
was designed to “ban the practice of Surprise Medical Billing.”1 Governor Whitmer, in her State  
of the State Address commented that the legislation she signed put an “…end to surprise  
medical billing.”2 These statements, by members of opposite parties and different branches of  
government, confirm the intent of the statute was intended to offer broad-based protections  
and we encourage the Department of Insurance and Financial Services (DIFS) and the  
Department of Licensing and Regulatory Affairs (LARA) to utilize all regulatory authority to  
ensure the practice of Surprise Medical Billing is stopped and violators of these Acts are  
deterred from future surprise medical bills.  
Specific Commentary on  
Surprise Medical Billing Draft Rules  
The Proposed Surprise Medical Billing Rules (“Proposed Rules”) should be amended to reflect  
the following changes:  
CR 500.243(1) Request for Calculation Review Rule 3  
As Proposed by DIFS: A nonparticipating provider must make a request for calculation  
review on a form provided by the department.  
1 Representative Roger Hauck and Frank Liberati’s Testimony on October 17, 2019 House Health Policy  
Committee. Accessed February 18, 2021.  
2 Governor Gretchen Whitmer’s State of the State Address, January 27, 2021, Accessed February 18, 2021  
1
MAHP Proposed: A nonparticipating provider must make a detailed request, which  
includes the nonparticipating provider’s rationale, for calculation review on a form  
provided by the department.  
Rationale: Under the proposed rules, Carriers must produce the data and information,  
which includes provider type and region, upon which its reimbursement was issued. In  
order to specifically address any nonparticipating provider’s request for rate review,  
the nonparticipating provider should be required to submit a detailed reasoning as to  
why it believes the reimbursement was incorrect.  
CR 500.243(2) Request for Calculation Review Rule 3  
As Proposed by DIFS: Request data on the carrier’s median amount or any documents,  
materials, or other information the department believes is necessary to assist in  
reviewing the request for calculation review.  
MAHP Proposed: Request data on the carrier’s median amount or any documents,  
materials, or other information the department believes is necessary to assist in  
reviewing the request for calculation review. The department shall provide the  
carrier with a written reasoning for requesting any materials it believes are  
necessary beyond the median amount calculation.  
Rationale: The statute is very limited regarding the data production for a rate review  
case. The statutory language is that the department may request data or other  
information that the department believes is necessary. Thus, if additional information is  
required beyond the rate calculation a stated reason as to how the department  
developed its belief should be required.  
CR 500.243(3) Request for Calculation Review Rule 3  
As Proposed by DIFS: A carrier must respond within 7 days of the date of the  
department’s request under subrule (2)(b) of this rule. If the information provided is  
incomplete, the department may, at its discretion, request additional information, or  
issue a determination based solely on the information provided as of the date on which  
the carrier’s response was due. If the department makes 1 or more requests for  
additional information, the department shall extend the time period permitted for the  
carrier’s response for a number of days the department considers appropriate.  
MAHP Proposed: A carrier must respond within 14 days, excluding any state-  
recognized holidays, of the date of the department’s request under subrule (2)(b) of  
this rule. If the information provided is incomplete, the department may, at its  
discretion and with a description as to why the department believes the information  
is incomplete, request additional information, or issue a determination based solely on  
the information provided as of the date on which the carrier’s response was due. If the  
2
department makes 1 or more requests for additional information, the department shall  
extend the time period permitted for the carrier’s response by 14 days.  
Rationale: Since there is no timeline defined in the statute, all timeframes should be  
consistent. DIFS has taken 14 days in order to start its review under 500.243(2).  
Carrier’s responses as well as responses to any additional information requests should  
receive the same grace period for response.  
MAHP appreciates the opportunity to comment on these proposed rules and our Plans look  
forward to collaborating with DIFS to respond to any legitimate nonparticipating provider  
concerns related to their reimbursement.  
Prepared By:  
Jeff Romback  
Deputy Director, Policy and Planning  
Michigan Association of Health Plans  
517-253-1004 (o)  
248-255-2952 (c)  
3
(Proposed Rule Modifications for Consideration TeamHealth 2-2-21)  
DEPARTMENT OF INSURANCE AND FINANCIAL SERVICES  
INSURANCE  
SURPRISE MEDICAL BILLING  
Filed with the secretary of state on  
These rules take effect immediately upon filing with the secretary of state unless adopted  
under section 33, 44, or 45a (6) of the administrative procedures act of 1969, 1969 PA 306,  
MCL 24.233, 24.244, or 24.245a. Rules adopted under these sections become effective 7  
days after filing with the secretary of state.  
(By authority conferred on the director of the department of insurance and financial services  
by section 24517 of the public health code, 1978 PA 368, MCL 333.24517)  
R 500.241, R 500.242, R 500.243, R 500.244, and R 500.245 are added to the Michigan  
Administrative Code as follows:  
R 500.241 Definitions.  
Rule 1. (1) As used in these rules:  
(a) “Act” means the public health code, 1978 PA 368, MCL 333.1101 to 333.25211.  
(b) “Median amount” means the median amount negotiated by the carrier for the region and  
provider specialty, excluding any in-network coinsurance, copayments, or deductibles. The  
carrier shall determine the region and provider specialty.  
(i) THE MEDIAN AMOUNT SHALL REFLECT THE ACTUAL AMOUNTS  
PAID TO CONTRACTED PROVIDERS IN THE YEAR [2019], KNOWN AS THE BASE  
YEAR.  
(ii) THE BASE YEAR SHALL BE ADJUSTED IN AN AMOUNT EQUAL TO  
THE CHANGE IN THE ANNUAL CONSUMER PRICE INDEX FOLLOWING THE  
URBAN (CPI-U) TO REFLECT THE MEDIAN AMOUNT IN THE CURRENT BENEFIT  
YEAR.  
(iii) THE MEDIAN AMOUNT SHALL BE REFLECTIVE OF PAYMENTS  
MADE SOLELY TO INDIVIDUALLY CONTRACTED PROVIDERS, EACH OF WHOM  
WERE CONTRACTED WITH THE CARRIER IN THE NONPARTICIPATING  
PROVIDER’S RECOGNIZED SPECIALTY DURING THE BASE YEAR.  
(iv) THE DEPARTMENT SHALL ENSURE THAT THE MEDIAN AMOUNT IS  
WEIGHTED IN A MANNER THAT BEST REPRESENTS THE FREQUENCY OF  
PAYMENTS ISSUED TO INDIVIDUALLY CONTRACTED PROVIDERS IN THE  
NONPARTICIPATING PROVIDER’S RECOGNIZED SPECIALTY DURING THE BASE  
YEAR.  
(v) THE MEDIAN AMOUNT SHALL NOT REFLECT PAYMENTS MADE TO  
CONTRACTED PROVIDERS OR PROVIDER GROUPS WHO WERE NOT LISTED IN  
2
THE CARRIER’S PROVIDER DIRECTORY UNDER THE SAME SPECIALTY AS THAT  
OF THE NONPARTICIPATING PROVIDER.  
(c) “COMPLICATING FACTOR’ MEANS:  
(i) A FACTOR THAT IS NOT NORMALLY INCIDENT TO A HEALTH CARE  
SERVICE, INCLUDING, BUT NOT LIMITED TO THE FOLLOWING:  
(a) INCREASED INTENSITY, TIME, OR TECHNICAL DIFFICULTY  
OF THE HEALTH CARE SERVICE;  
(b) THE SEVERITY OF THE PATIENT’S CONDITION; AND,  
(c) THE PHYSICAL OR MENTAL EFFORT REQUIRED IN  
PROVIDING THE HEALTH CARE SERVICE.  
(ii) THE DEPARTMENT SHALL DELINEATE MEDICAL CONDITIONS THAT  
CONSTITUTE ‘COMPLICATING FACTORS’ BY UTILIZING GENERALLY  
ACCEPTED MEDICAL DIAGNOSIS AND CODING TERMINOLOGY TOOLS AND  
RESOURCES DETERMINED BY THE INTERNATIONAL CLASSIFICATION OF  
DISEASE, TENTH EDITION (ICD-10), AND THE AMERICAN MEDICAL  
ASSOCIATION’S COMMON PROCEDURE TERMINOLOGY (CPT) WITH BOTH  
SERVING AS RECOGNIZED RESOURCES FOR CARRYING OUT THE ACT, IN  
ACCORDANCE WITH R500.245(1).  
(2) THE DEPARTMENT SHALL INSTRUCT CARRIER’S TO IDENTIFY A  
METHOD BY WHICH A NONPARTICIPATING PROVIDER MAY INDICATE THE  
PRESENCE OF A ‘COMPLICATING FACTOR’ ON THE CLAIM SUBMISSION FORM  
WHETHER FILED ELECTRONICALLY OR ON PAPER, WHICH SHALL BE DEEMED  
SUFFICIENT FOR THE CARRIER TO RECOGNIZE, PROCESS AND ISSUE A  
SUPPLEMENTAL OUT-OF-NETWORK PAYMENT IN ACCORDANCE WITH THIS  
ACT.  
THE DEPARTMENT SHALL REQUIRE THE CARRIER TO NOTICE THE  
NONPARTICIPATING PROVIDER AS PART OF THE CARRIER’S EXPLANATION OF  
BENEFITS, EITHER ELECTRONICALLY OR IN PAPER FORM, THAT THE MEDIAN  
AMOUNT PAYMENT ISSUED INCLUDES A SUPPLEMENTAL COMPLICATING  
FACTORPAYMENT AT THE STIPULATED ADD-ON PAYMENT PERCENTAGE  
INCREASE REQUIRED BY THIS ACT.  
THE CARRIER MAY ALSO CHOOSE TO DENY THE NONPARTICIPATING  
PROVIDER’S CLAIM FOR A SUPPLEMENTAL ‘COMPLICATING FACTOR’  
PAYMENT BUT MUST NOTIFY THE NONPARTICIPATING PROVIDER BY  
COMMUNICATING ANY DENIAL ON ITS EXPLANATION OF BENEFITS FORM,  
EITHER ELECTRONICALLY OR ON PAPER, AND IN DOING SO, ADVISE THE NON-  
PARTICIPATING PROVIDER THAT HE OR SHE MAY CHOOSE TO APPEAL THE  
CARRIER’S DETERMINATION BY COMMUNICATING WITH THE DEPARTMENT  
ON A FORM SPECIFIED BY THE DEPARTMENT AND BY ACCESSING THE  
ARBITRATION PROVISIONS MADE AVAILABLE BY THE DEPARTMENT.  
(3) THE DEPARTMENT SHALL REQUIRE THE CARRIER TO IDENTIFY ON  
ALL MEMBER INSURANCE IDENTIFICATION CARDS AND EXPLANATION OF  
TH/AF/JK 2-2-21  
3
BENEFITS, EITHER ELECTRONICALLY OR ON PAPER, PLAN BENEFITS TO BE  
ADMINISTERED, PAID OR DENIED IN ACCORDANCE WITH THIS ACT.  
(4) THE DEPARTMENT SHALL ESTABLISH AND PUBLISH A SCHEDULE  
OR LIST, WHICH SHALL BE UPDATED ANNUALLY DELINEATING MEDICAL  
SERVICES AND CONDITIONS THE DEPARTMENT DEEMS MEET THE DEFINITION  
OF A ‘COMPLICATING FACTOR’.  
THE SCHEDULE THE DEPARTMENT PUBLISHES SHALL BE CROSS-  
REFERENCED TO GENERALLY ACCEPTED MEDICAL DOCUMENTATION TOOLS  
AND RESOURCES IN ACCORDANCE WITH 500.241, SUBSECTION (1)(C) OF THE  
ACT, MCL 333.24511.  
(5) A term defined in the act for the purposes of article 18 of the act, MCL 333.24501  
to 333.24517, has the same meaning when used in these rules.  
R 500.242 Scope and applicability.  
Rule 2. These rules do the following:  
(a) Establish procedures for the department to review and resolve requests for calculation  
review OF THE MEDIAN AMOUNT submitted pursuant to section 24510 of the act, MCL  
333.24510.  
(b) Establish procedures for approving arbitrators to provide binding arbitration pursuant to  
section 24511 of the act, MCL 333.24511.  
R 500.243 Requests for calculation review.  
Rule 3. (1) A nonparticipating provider must make a request for calculation review on a  
form provided by the department.  
(2) In response to a request from a nonparticipating provider for a calculation review  
under section 24510 of the act, MCL 333.24510, the department shall do the following within  
14 days of the date of the request:  
(a) Notify the carrier of the request for a calculation review.  
(b) Request data on the carrier’s median amount or any documents, materials, or other  
information the department believes is necessary to assist in reviewing the request for  
calculation review.  
(c) CONSULT OR REQUEST SUPPORTING INFORMATION FROM A NATIONALLY  
RECOGNIZED PHYSICIAN ALLOWABLE DATABASE IN ACCORDANCE WITH  
R500.244(2).  
(3) A carrier must respond within 7 days of the date of the department’s request  
under subrule (2)(b) of this rule. If the information provided is incomplete, the department  
may, at its discretion, request additional information, or issue a determination based solely on  
the information provided as of the date on which the carrier’s response was due. If the  
department makes 1 or more requests for additional information, the department shall extend  
the time period permitted for the carrier’s response for a number of days the department  
considers appropriate.  
(4) The department shall issue a determination resolving the request for a calculation  
review no later than 14 days after the carrier submits a timely and complete response under  
TH/AF/JK 2-2-21  
4
subrule (3) of this rule or after the expiration of the time period within which the carrier was  
required to respond, including any extensions provided under subrule (3) of this rule.  
R 500.244 Median amount; access to database.  
Rule 4. (1) Subject to subrule (3) of this rule, a carrier may satisfy the requirement under R  
500.243 by providing the department with access to a database that contains all of the carrier’s  
median amounts. The database must meet all of the following requirements:  
(a) Be updated no less frequently than quarterly.  
(b) Be searchable by region, provider specialty, and health care service.  
(c) Include negotiated rates for all health care services covered by the carrier,  
GEOGRAPHICALLY ADJUSTED AND IF APPLICABLE, ISOLATED BY PLAN  
PRODUCT TYPE SO NOT TO BLEND OR MERGE VARYING CONTRACT RATE  
STRUCTURES FOR THE PURPOSES OF ARTIFICIALLY ADJUSTING THE MEDAIN.  
THIS SHALL BE FURTHER LIMITED TO PROVIDERS REPORTED IN THE  
CARRIER’S CURRENTLY PUBLISHED PROVIDER DIRECTORY, SORTED FOR  
EACH GIVEN SPECIALTY;  
(d) REPRESENT CONTRACTED PAYMENT RATES FOR COMMERCIAL HEALTH  
BENEFIT PLANS ONLY, THAT ARE REGULATED BY THE DEPARTMENT, AND  
WHICH. SHALL NOT INCLUDE PROVIDER CONTRACT RATES ASSOCIATED  
WITH BENEFIT PLANS THE CARRIER ADMINISTERS ON BEHALF OF MEDICARE,  
MEDICAID OR OTHER GOVERNMENT HEALTH BENEFIT PROGRAMS.  
(e) Be continuously accessible to the department.  
(2) For the purposes of conducting a calculation review under section 24510 of the  
act, MCL 333.24510, the department may, at its discretion, consult any external database  
described under section 24510(2) of the act, MCL 333.24510, without regard to whether a  
carrier made the database accessible to the department or whether the database otherwise  
meets the requirements under subrule (1) of this rule.  
SUCH  
DATABASE  
SHALL  
BE  
NATIONALLY  
RECOGNIZED,  
GEOGRAPHICALLY ADJUSTED AND SPECIALTY SPECIFIC, SORTED BY  
GEOGRAPHIC ALLOWABLE PAYMENT PERCENTILES, PROCURED BY A NOT-  
FOR-PROFIT ENTITY, WHICH IS NOT AFFILIATED, EITHER DIRECTLY OR  
INDIRECTLY, WITH AN INSURANCE CARRIER OR HEALTH. BENEFIT PLAN.  
(3) A carrier’s provision of access to a database under this rule does not preclude  
the department from requesting additional documents, materials, or other information that the  
department determines is necessary for conducting a review under section 24510 of the act,  
MCL 333.24510.  
R 500.245 Approval of arbitrators.  
Rule 5. (1) The department shall create and maintain a list of arbitrators trained by the  
American Arbitration Association or American Health Lawyers Association WHO POSSESS  
KNOWLEDGE OF MEDICAL REIMBURSEMENT AND EXPERIENCE IN THE USE OF  
MEDICAL TERMINOLOGY AND MEDICAL CODING, INCLUDING BUT NOT  
LIMITED TO THE INTERNATIONAL CLASSIFICATION OF DISEASE, TENTH  
EDITION (ICD-10), AND THE AMERICAN MEDICAL ASSOCIATION’S COMMON  
PROCEDURE TERMINOLOGY (CPT) AND WHO SHALL BE approved by the director.  
TH/AF/JK 2-2-21  
5
This list must be updated no less frequently than annually and must be posted on the  
department’s website.  
THE ARBITRATOR AND DEPARTMENT MAY CHOOSE TO SEEK THE  
ASSISTANCE OF MEDICAL PROFESSIONALS LICENSED IN THE STATE OF  
MICHIGAN AND TRAINED IN THE MEDICAL SPECIALITY IN THE DISPUTE IN  
QUESTION FOR THE PURPOSE OF ASSISTING THE ARBITRATOR RULE ON THE  
PRESENCE OF OR LACK THEREOF OF A COMPLICATING FACTOR.  
THE SELECTED MEDICAL PROFESSIONAL SHALL HAVE NO  
AFFILIATION OR RELATIONSHIP WITH EITHER OF THE PARTIES.  
(2) Arbitrators seeking to be included in the list under subrule (1) of this rule must  
apply on a form prescribed by the department.  
(3) The department shall approve or disapprove an application no later than 60 days  
after the date of receipt of the application. Applicants whose application has been disapproved  
may reapply at any time.  
(4) If approved for inclusion in the list under subrule (1) of this rule, arbitrators  
must annually provide to the department, on a form prescribed by the department, an  
attestation acknowledging that the information provided to the department in the arbitrator’s  
application under subrule (2) of this rule remains complete and accurate.  
(5) Arbitrators included on the department’s list under subrule (1) of this rule must  
notify the department of any changes to the information contained in the arbitrator’s  
application under subrule (2) of this rule within 30 days of the change. An arbitrator’s failure  
to inform the department of these changes may result in revocation of the arbitrator’s approval  
and removal from the list under subrule (1) of this rule.  
TH/AF/JK 2-2-21  
;