Current through Vol. 24-16, September 15, 2024
Rule 101.
(1)
These rules do all of the following:
(a)
Establish procedures by which the employer shall furnish, or cause to be
furnished, to an employee who receives a personal injury arising out of and in
the course of employment, reasonable medical, surgical, and hospital services
and medicines, or other attendance or treatment recognized by the laws of the
state as legal, when needed. The employer shall also supply to the injured
employee dental services, crutches, artificial limbs, eyes, teeth, eyeglasses,
hearing apparatus, and other appliances necessary to cure, so far as reasonably
possible, and relieve from the effects of the injury.
(b) Establish schedules of maximum fees by a
health facility or health care provider for such treatment or attendance,
service, device, apparatus, or medicine.
(c) Establish procedures by which a health
care provider shall be paid.
(d)
Provide for the identification of utilization of health care and health
services above the usual range of utilization for such services, based on
medically accepted standards, and provide for acquiring by a carrier and by the
agency the necessary records, medical bills, and other information concerning
any health care or health service under review.
(e) Establish a system for the evaluation by
a carrier of the appropriateness in terms of both the level of and the quality
of health care and health services provided to injured employees, based upon
medically accepted standards.
(f)
Authorize carriers to withhold or recover payment from health facilities or
health care providers, that have made excessive charges or that have required
unjustified treatment, hospitalization, or visits.
(g) Provide for the review by the agency of
the records and medical bills of any health facility or health care provider
that have been determined by a carrier not to comply with the schedule of
charges established by these rules or to require unjustified treatment,
hospitalization, or office visits.
(h) Provide for the certification by the
agency of the carrier's professional health care review program.
(i) Establish that when a health care
facility or health care provider provides health care or health care service
that is not usually associated with, is longer in duration than, is more
frequent than, or extends over a greater number of days than that health care
or service usually does with the diagnosis or condition for which the patient
is being treated, the health facility or health care provider may be required
by the carrier to explain the necessity in writing.
(j) Provide for the interaction of the agency
and the department for the utilization of departmental procedures for the
resolution of workers' compensation disputes.
(k) Are intended for the implementation and
enforcement of section 315(2) to (9) of the act, MCL 418.315, and provide for
the implementation of the agency's review and decision responsibility vested in
it by those statutory provisions. The rules and definitions are not intended to
supersede or modify the workers' disability compensation act, the
administrative rules of practice of the agency, or court decisions interpreting
the act or the agency's administrative rules.
(2) An independent medical examination is
exempt from these rules and may be requested by a carrier or an employee. An
independent medical examination, (IME), shall be conducted by a practitioner
other than the treating practitioner. Reimbursement for the independent medical
evaluation shall be based on a contractual agreement between the provider of
the independent medical evaluation and the party requesting the
examination.
(3) These rules and
the fee schedule do not pertain to health care services that are rendered by an
employer to its employee in an employer-owned and employer-operated
clinic.
(4) Payments made pursuant
to a redemption order or a voluntary payment agreement signed by a magistrate,
director, or director's representative are subject to these rules and fee
schedule.
(5) If a carrier and a
provider have a contractual agreement designed to reduce the cost of workers'
compensation health care services below what would be the aggregate amount if
the fee schedule were applicable, the contractual agreement shall be exempt
from the fee schedule. The carrier shall do both of the following:
(a) Perform technical and professional review
procedures.
(b) Provide the annual
medical payment report to the agency's health care services division.
