Michigan Administrative Code
Department - Labor and Economic Opportunity
Workers Compensation Agency
Workers' Compensation Health Care Services Rules
Part 10 - REIMBURSEMENT
Subpart A - Eligibility for premium tax credit
Section R. 418.101016 - Reimbursement; payment ratio methodology

Universal Citation: MI Admin Code R. 418.101016

Current through Vol. 24-16, September 15, 2024

Rule 1016.

(1) A hospital licensed in Michigan billing facility services shall be reimbursed using the maximum payment ratio methodology for the following services:

(a) Inpatient or observation care.

(b) Emergency department services.

(c) Occupational, physical, and speech therapy services.

(d) Outpatient surgeries.

(e) Laboratory services and outpatient services. If a carrier pays a properly submitted bill or unadjusted portion of the bill within 30 days of receipt, then the payment is calculated by multiplying the charges times the hospital's maximum payment ratio times a multiplier of 107%. If a carrier pays the bill after 30 days, then the multiplier shall be 110% allowing for a 3% late fee.

(2) When a hospital outside the state of Michigan submits a bill for facility services, the carrier may initially process payment by using the method described in subrule (1) of this rule, applying the average maximum payment ratio, as published in the health care services manual. If the facility located outside of Michigan does not accept reimbursement according to Michigan health care services rules, then the carrier shall negotiate the charges with the out-of-state facility or reimburse the facility according to the laws of the state where the facility is located.

(3) If applying the ratio methodology results in an amount greater than the hospital's charge, the carrier shall reimburse the hospital's charge. The only time a carrier shall pay in excess of the charge is if a properly submitted bill was not paid within 30 days and, in that instance, the carrier shall reimburse the charge plus a 3% late fee.

(4) Observation care shall not be for more than 24 hours. If the patient does not meet admission criteria according to the length of stay guidelines, then the patient shall be discharged from observation care.

Disclaimer: These regulations may not be the most recent version. Michigan may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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