Michigan

Here you will find Michigan-specific elements relative to your use of PIP Fee.

    Effective Date and Scope

  • Pre–July 2, 2021, Services: Services provided before July 2, 2021, are reimbursed under the prior framework and are not capped by the new schedule.
  • Post–July 1, 2021, Services: All treatment dates of service after July 1, 2021, are subject to the fee schedule caps.

    • How the Fee Schedule Works

  • Medicare Benchmarking: For services with a Medicare code, reimbursement is tied to a percentage of the Medicare fee schedule. The percentage decreases over time, beginning at 200% in 2021–2022 and tapering in later years.
  • Non-Medicare Services: Where no Medicare rate exists, the statute imposes a cap based on the provider’s previous charges.

    • See how to use the CDM field in PIP Fee ›

  • Ongoing Adjustments: Providers and insurers must track the statutory percentage for the applicable calendar year to ensure compliance.

    • Practical Implications

  • Providers: Must align billing practices with the statutory caps or risk partial denials.
  • Insurers: Must apply the correct fee schedule limitations in adjusting claims and defending against overbilling.
  • Attorneys: Should anticipate disputes where providers exceed caps, where no Medicare equivalent exists, or where historical charge data is contested.

    • Streamlining the Process with PIP Fee

    The statutory framework is complex, and manual application of the fee schedule is unbearably time-consuming and error-prone. PIP Fee does the heavy lifting for you:

  • Instantly applies the correct fee schedule based on the date of service.
  • Accounts for Medicare-linked and non-Medicare services alike.
  • Provides accurate reimbursement calculations that help providers bill correctly and insurers evaluate claims confidently.

    • In short: PIP Fee ensures compliance with Michigan’s no-fault reform—without the guesswork. Sign up today.

    Core Methodology

  • Medicare-Based Benchmarking: PIP Fee uses applicable Medicare fee schedules as the baseline and applies statutory multipliers under MCL 500.3157.
  • Fee Schedule Focus: Calculations are derived from published fee schedule amounts and provider-specific tiers.

    • Statutory Scope

  • Primary Framework: PIP Fee applies the complex reimbursement structure under MCL 500.3157, including Medicare-based fee schedule caps and Section 7 charge-based calculations where no Medicare amount exists.
  • Tiered Reimbursement: Calculations reflect the enhanced reimbursement tiers for specific providers under subsections (2) (default), (3) (indigent/rehab), (5) (high indigent), and (6) (level I/II trauma centers).
  • Annual Adjustments: Where applicable, calculations reflect the adjustment mechanism set forth in subsection (9), including annual CPI updates for non-Medicare services.

    • What Is Not Included

  • Patient-specific payment factors such as deductibles, coinsurance, or supplemental coverage.
  • Nuanced Medicare payment adjustments unrelated to the fee schedule rates, such as bad debt adjustments, sequestration, or specific quality-based reconciliation processes.

    • Practical Guidance

    PIP Fee provides a general application of Michigan’s statutory fee schedule framework across several provider tiers. For complex billing scenarios, including specialized facility-level adjustments or broader contract-based determinations, users should consider the specific legal and clinical context of the claim.

    Understanding the Sections

  • Section 2 (default)
    This is the standard category for the majority of physicians, clinics, and healthcare institutions. Under MCL 500.3157(2), these providers are eligible for the baseline reimbursement rates.
  • Section 3 (20–29% indigent volume or rehab)
    This tier applies to providers with an indigent patient volume between 20% and 29% or "freestanding rehabilitation facilities." To qualify as a freestanding rehabilitation facility, a hospital must meet specific criteria.
  • Section 5 (30%+ indigent volume)
    This enhanced tier is reserved for providers that serve a high volume of indigent patients, specifically 30% or more of their total treatment or training. These providers must provide necessary documentation annually to certify their eligibility for this top-tier reimbursement rate.
  • Section 6 (level I or II trauma center)
    This section applies specifically to hospitals verified as level I or level II trauma centers. This higher rate is only applicable for treatment of emergency medical conditions rendered before the patient is stabilized and transferred.
  • Section 7 (no Medicare amount payable)
    If Medicare does not provide an amount payable for a specific treatment or training, reimbursement is based on a percentage of the provider's Charge Description Master (CDM) in effect on January 1, 2019. If the provider did not have a CDM, the percentage is applied to the average amount the person charged for the treatment on that same date.

    When to Use It

    The CDM price is only required when:

  • The code you entered is not found in any fee schedule; and
  • You have the official CDM price from January 1, 2019.

    • If you don’t have the CDM price, leave the field blank. The system will automatically calculate the amount by multiplying your Net Charge (Gross Charge − Adjustment) using the percentages in MCL 500.3157(7).

    What Happens When You Use It

  • If left blank:
    The system uses Net Charge × 3157(7) percentage to determine the allowed amount.
  • If filled in:
    The system ignores the Net Charge and instead uses CDM Price × 3157(7) percentage.

    • Example

  • Gross Charge: $1,000
  • Adjustment: $100
  • Net Charge: $900
  • CDM Price (Jan. 1, 2019): $800

    • If CDM Price is left blank → $900 × percentage from MCL 500.3157(7).
    If CDM Price is filled in → $800 × percentage from MCL 500.3157(7).