IMPORTANT ANNOUCEMENTS

MICHIGAN SUPREME COURT ELECTION

NOVEMBER 6, 2012

            As you know, the current Michigan Supreme Court has issued scores of legal decisions over the past decade that favor the insurance industry, corporations and business interests over and over again to the detriment of your individual rights.   A review of the last decade of Michigan Supreme Court opinions reveals several things: the consistent biases of the majority justices, their uncalled for vicious personal attacks on the minority justices who disagree with them and most of all their disdain for injured people.  Indeed, a 2008 study by The Law School of the University of Chicago ranked the Michigan Supreme Court the lowest in independence (impartiality) among the 52 highest courts in the country. The study defined independence as "the judge's ability to withstand partisan pressures, or disinclination to indulge partisan preferences when deciding cases." fn1  The majority's lack of professionalism and their ideological partisanship is an embarrassment to the people of this great state. We deserve better.

            On November 6 we are going to have the chance to right this imbalance.  As you know, the Michigan Supreme Court Justices are elected by Michigan citizens.  This year the seats held by Justices Stephen J. Markman and Brian K. Zahra are up for election.   Justice Marilyn Kelly has reached the mandatory retirement age, so there will be three seats to be filled this election year.  We are supporting three very dynamic candidates to replace these justices.  These are:  Judge Shelia Johnson (Southfield District Court) at www.judgesheliajohnson.com; Judge Connie Marie Kelly (Wayne County Circuit Court) at www.conniekellyforjustice.com; and Dean (and Law Professor) Bridget McCormick (The University of Michigan Law School) at www.mccormackforjustice.com.   These candidates promise to bring transparency, less partisan politics and more balance to the court.  They will work tirelessly to protect us, our children and our communities.

            We urge you to go to their websites and their facebook pages to learn more about them.  We ask you to join with us in asking your friends, families and neighbors to vote for these individuals to bring back sound legal reasoning and true justice to our highest court.

FN1. Stephen J. Choi, Mitu Gulati and Eric A. Posner, Which States have the Best (and Worst) High Courts?, John M. Olin Law & Economics Working Paper No. 405, 2008, The Law School The University of Chicago

FOR PROVIDERS

BILLING QUESTIONS:  

CORVEL REVIEW PRACTICES 

Corvel (a third party administrator that some auto insurance carriers are working with) recently told a medical office (apparently as of May 2012) that they will no longer reimburse for therapy sessions with durations of greater than 1 hour.   We believe this is inconsistent with the No-Fault Act, and have the following thoughts:

MCL 500.3107 of the Michigan No-Fault Act states that personal protection insurance benefits are payable for: (a) allowable expenses consisting of all reasonable charges incurred for reasonably necessary products, services and accommodations for an injured person's care, recovery or rehabilitation.

If Corvel is denying reimbursement for therapy sessions with durations of greater than one hour, they must be taking the position that therapy after the first hour is not reasonably necessary under MCL 500.3107.  Corvel is certainly within their rights to take such a position but to support this position they must have medical support (medical expert opinion) that therapy after the first hour is not reasonably necessary.  Of course, the medical opinion of your physicians is that the therapy after the first hour is reasonably necessary.

At this point, you should draft a letter of medical necessity to provide to the insurer(s) that denied the claim(s) at the recommendation of Corvel.  You should be as specific as possible in stating why this treatment is reasonably necessary for auto accident-related injuries. 

Although you are having a problem with Corvel, they are a TPA and your problem is really with the insurer(s) who are taking their advice and denying payment.  While you have to respond to Corvel through their appeal process, if it comes down to a lawsuit, the defendant would be the applicable auto insurer.  Remember, a lawsuit must be filed within one year of the date of service or the insurer can claim that the expense is extinguished by virtue of the statute of limitations.

If you are not successful with your appeal to Corvel, you may want to pursue a "test case" or a few "test cases" where the therapy after one hour is particularly reasonably necessary.  While a win on such a case may not establish a legally binding "precedent", it may have the practical effect of causing the insurer to stop challenging the bills.

HCFA 1500 BOX 27

A medical provider recently advised me of an interesting misinterpretation of the use of Box 27 of the HCFA 1500 form.  An auto insurance claims representative took the position that if the medical provider checks "yes" for Box 27 (which asks "Accept Assignment?"), the provider is indicating (1) that they want the payment to go to the provider and (2) they accept the amount paid as payment in full.  The claims representative then told her that if the medical provider checks "no" for Box 27, they are indicating that the payment should go to the patient.

My research revealed that when sending claims electronically, there are differences between how Box 27 is used for commercial claims versus government claims (such as Medicare). The following is a clarification of these differences:

For government claims (Medicare, CHAMPUS, etc.): Box 27 has two meanings: (1) It indicates who is to receive payment.  "Yes" indicates payment should go to the provider shown in Box 33.  "No" indicates payment should go to the patient; and (2) If "Yes" is checked, the provider indicated in Box 33 has agreed to accept as "payment-in-full" whatever Medicare is going to pay. No further charges are to be billed to the patient.

For commercial claims: If the physician or clinic does not have a contract with the commercial carrier, Box 27 has only one meaning-it indicates to whom payment is to be made.  Whether a "Yes" or "No" is checked, the physician can still bill the patient for unpaid balances due for services rendered.

With a commercial claim like auto insurance, you are not accepting whatever the auto insurance decides is reasonable and customary just because you have checked "yes" in box 27.  You may still balance bill the patient for the balance.

The reason that the auto insurance company is trying to promote this misinterpretation of Box 27 could be because when the patient is balance billed, it is up to the auto insurer to indemnify and hold the patient harmless for the difference.  The auto insurer must then pay an attorney if the provider sues it's insured.

NO-FAULT SURVIVORS LOSS SETTLEMENT 

 Wayne Miller recently settled a claim for survivors loss for $115,000. The case involved an 80 year old man who, though he had a variety of medical conditions, was still able to work. He was hit as a pedestrian, and suffered a fractured knee. The resulting inability to walk led to deconditioning, which aggravated all of his medical conditions. He lived for 4 months before passing. The No-Fault insurer initially took the position that the death was due to the medical conditions and not the motor vehicle injury. However, the insurer could not dispute the medical opinion evidence that we submitted. Ultimately, they paid 100% of the amount claimed, plus substantial No-Fault penalties.