Phase II

Provider Survey Results from

a Study Tracking
Impact of Fee Changes in
No-Fault Auto Insurance Reform

August 2022
Auto No-Fault Fee Change Impact Study: Phase II

Table of Contents
Executive Summary ........................................................................................................ 2
Results ......................................................................................................................... 2
About this Study ........................................................................................................... 4
Methodology.................................................................................................................... 5
Survey Development .................................................................................................... 5
Survey Implementation ................................................................................................ 5
Survey Distribution ....................................................................................................... 5
Internal Review Board Approval................................................................................... 5
Provider Survey Results .................................................................................................. 6
Services Provided and Impacted ................................................................................. 6
Impact on business operations .................................................................................... 8
Impact of the 200% reimbursement cap for Medicare payable codes .......................... 9
Impact of 55% of 2019 charges for non-payable Medicare codes ............................. 11
Reimbursement.......................................................................................................... 12
Working with DIFS and Insurance Adjusters .............................................................. 13
Provider perspectives ................................................................................................ 15

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Auto No-Fault Fee Change Impact Study: Phase II

Executive Summary
The Brain Injury Association of Michigan (BIAMI) commissioned this independent study
by the Michigan Public Health Institute (MPHI) to document the impact of the fee
structure changes in the 2019 Michigan no-fault auto insurance reform law that took
effect on July 1, 2021, on the availability of services for people with catastrophic injuries
resulting from an auto crash. MPHI was chosen because of its expertise and depth of
understanding of public health research. This report summarizes the results from the
second survey of brain injury service providers, distributed between March 9 and May
15, 2022. The report on the first survey was released in January 2022.

Results
General Impact
• 209 unique organizations participated in the second survey, including 166
organizations that also participated in the first survey
• The 73 organizations with data on amount of revenue loss reported a combined total
of $81,366,027 loss in revenue during the last 12-month period
• The 109 organizations with data on percentage of revenue loss reported an average
of 41% loss of revenue during the last 12-month period
• Out of 19,994 employees from the 154 organizations with employment data, 4,082
(29%) jobs were eliminated since July 2021
• In terms of patients with auto insurance funding, the 144 organizations with patient
count data reported serving a total of 15,596 patients before July 2021 and 8,739
currently, that is a total of 6,857 discharges and an average of 42% reduction in
their capacity of serving patients with auto insurance funding since July 2021
• Among the top five services most frequently provided, 73-90% of organizations
reported that these services have been either eliminated, reduced, or impacted in
other ways
Eliminated Reduced Other impact Not impacted Don't know

Residential/ 12% 71% 7%

Support Living (41)

Community/Home
9% 67% 5%
Based Therapy (43)

Outpatient Therapy/
8% 59% 6%
Treatment (51)

Private Duty/
20% 54% 4%
Attendant Care (56)

Case Management
(55) 4% 51% 20%

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Auto No-Fault Fee Change Impact Study: Phase II

• Among the 209 organizations, there have been 10 business closures due to the
changes and expected 14 more closures in the next 12 months.

79 (38%) Modified the types of patients they can serve

72 (34%) Discharged some patients with auto insurance funding

67 (32%) Reduced the services/products significantly

14 (7%) Planned to close completely in the next 12 months

Impact of Fee Caps and Reimbursement

• 119 (57%) organizations reported being impacted by the 55% fee cap, while 52
(25%) reported being impacted by the 200% Medicare cap
• Of the 99 organizations impacted by the 55% cap and with data on profit margin, 67
(68%) reported no more than 20% annual profit margin prior to July 2021
• Of the 48 organizations impacted by the 200% cap and with data on Medicare
reimbursement rates, 24 (50%) reported that none of their Medicare payable
claims have been paid at 200% Medicare rates since July 2021
• Of the 140 organizations with data on overall reimbursement, 7 (5%) reported that
they had not received any reimbursement since July 2021
• The 84 organizations with data on denied services reported an average of 28% of
their patients had been denied services since July 2021, due to insurance
company utilization review process

Utilization Review Process with DIFS

• 49 organizations have filed appeals with DIFS through utilization review process on
denied services since July 2021. Of those 36 (73%) have not gotten any services
reinstated

36 (73%) 13 (27%)

No services reinstated Some services reinstated

• 48 organizations have filed a total of 1,284 complaints to DIFS since July 2021, 176
(14%) have been resolved in their favor
Resolved Total complaints filed
176 (14%) 1,284
0 200 400 600 800 1000 1200

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Auto No-Fault Fee Change Impact Study: Phase II

About this Study

Limitations
The target population of this survey are providers representing the organizations that
provided services and care to auto crash survivors. MPHI does not have a mailing list of
the target population. The first survey was distributed as a public link, sent to BIAMI’s
networks and their members by BIAMI and partners. The respondent list from the first
survey was invited to participate in the second survey, and the second survey was also
distributed through a public link. There is no way to know whether the survey invitations
reached all target providers, and whether the respondents are representative of the
target population.

MPHI Research Team

MPHI is a public-private partner with a variety of public health, government, and
community organizations and is committed to conducting public health work based on
strong scientific evidence and the needs of Michigan residents. This study is conducted
by a team from MPHI’s Center for Data Management and Translational Research
(CDMTR), including Dr. Clare Tanner, director; Dr. Shaohui Zhai, Statistician; Dr.
Issidoros Sarinopoulos, Senior Research Scientist; and Kayla Kubehl, Research
Assistant.

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Auto No-Fault Fee Change Impact Study: Phase II

Methodology
Survey Development
The Auto Crash Service Providers Surveys were collaboratively developed by MPHI
and BIAMI. The surveys contained questions about their employer organizations, also
collected individual names and contact information in order to recontact them for the
subsequent surveys. MPHI researchers trained in survey development finalized all
questions to ensure readability, clarity, and lack of bias.

Survey Implementation
The survey was implemented in REDCap (Research Electronic Data Capture) by MPHI.
REDCap is a secure web application for building and managing online surveys and
databases. While REDCap can be used to collect virtually any type of data in any
environment (including compliance with 21 CFR Part 11, FISMA, HIPAA, and GDPR), it
is specifically geared to support online and offline data capture for research studies and
operations.

Survey Distribution
The second survey was distributed in two batches, one was by MPHI through email to
the first survey respondents who provided contact emails, the other was by BIAMI and
partners through a public link to their members and networks to recruit organizations
that did not respond to the first survey. The survey was distributed between March 9
and May 15, 2022. At least three rounds of reminders were sent out during the
distribution period.

Internal Review Board Approval

MPHI’s Internal Review Board (IRB) operates following FDA regulations and is formally
designated to review and monitor biomedical research involving human subjects with
the authority to approve or disapprove research. This review is designed to ensure
researchers protect the rights and welfare of research participants. The IRB review
assures appropriate steps are taken to protect the rights and welfare of research
participants. MPHI’s IRB panel reviews research protocols and related materials to
ensure protection of the rights and welfare of research participants.

The MPHI research team submitted a Human Participant Protections Application to the
MPHI IRB, and the approval of the project was granted on September 27, 2021.

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Auto No-Fault Fee Change Impact Study: Phase II

Provider Survey Results

Services Provided and Impacted
Respondents reported the services their organizations provided before July 2021, and
how these services were impacted by the fee caps that took effect in July 2021. The
chart on the next page presents the service categories and the percentages of the
organizations reporting these services being eliminated, reduced, other impact, or no
impact.
• The number of organizations that provided the listed services ranged from 4
(Orthotic/Prosthetics) to 56 (Private Duty/Attendant Care).
• Every type of service has been impacted – with a majority of organizations
across all service categories except three (Orthotic/Prosthetics, Chiropractic
Therapy, and Guardian/Conservator Services) reporting having to eliminate or
reduce services.
• The top 8 services provided by at least 20 organizations are, Private
Duty/Attendant Care, Case Management, Outpatient Therapy/Treatment,
Community/Home Based Therapy, Residential/Supported Living, Transportation,
Recreational Therapy, and Vocational Services/Counseling Services.
• Among these commonly provided 8 services, those most impacted are:
▪ Residential/Supported Living: 83% organizations reported eliminating or
reducing services
▪ Recreational Therapy: 77% organizations reported eliminating or reducing
services
▪ Community/Home Based Therapy: 76% organizations report eliminating or
reducing services
• It is also worth noting that 24% of Transportation and 20% of Private
Duty/Attendant Care services organizations reported eliminating those services
entirely.
• 32 organizations reported providing other services not in the answer options,
including general healthcare, medical technology, neuropsychology, driver
rehabilitation, and various therapy services. 62% of the organizations reported
these services being either eliminated, reduced, or impacted in other ways.
• Other impacts reported include, decreased or delayed reimbursement, reduced
salary and benefits, and reduced staff.

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Auto No-Fault Fee Change Impact Study: Phase II

Services provided and how they were impacted (n=209)

Impacted Eliminated Reduced Other impact Not impacted Don't know

Private Duty/Attendant Care (56) 20% 54% 4%

Case Management (55) 4% 51% 20%

Outpatient Therapy/Treatment (51) 8% 59% 6%

Community/Home Based Therapy (43) 9% 67% 5%

Residential/Supported Living (41) 12% 71% 7%

Transportation (38) 24% 47% 5%

Recreational Therapy (27) 7% 70% 11%

Vocational Services/Counseling (23) 17% 52% 26%

Day Treatment (15) 47% 53%

Durable Medical Equipment (DME) (15) 13% 60%

Home Modification (14) 64% 14%

Fitness Programs (12) 17% 75% 8%

Chiropractic Therapy (9) 11% 22%

Sheltered/Supported Work Program (8) 38% 50%

Guardian/Conservator Services (8) 25% 38%

Vehicle Modification (7) 71%

Oxygen/Ventilators (5) 40%

Orthotic/Prosthetics (4) 75%

Other Services (32) 6% 47% 9%

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Auto No-Fault Fee Change Impact Study: Phase II

Impact on business operations

Providers were asked about the impact on the general operations of their organizations.
• 79 (38%) organizations reported having to modify the types of patients they
serve, such as by looking at the insurance/PIP coverage to determine if they will
serve a new patient.
• 10 (5%) had to close completely, and another 14 (7%) plan to close in the next
12 months.
• 60 (29%) reported other impacts, including difficulty getting reimbursement from
insurance companies (partial payment, no payment, inconsistency in payment,
more required documentations), having lost money, having to cut employees
pay, and having to downsize the workforce.
Impact on organizational operations (n=209 organizations)

We have had to modify the types of patients we

79 (38%)
can serve

We have had to discharge some patients with

72 (34%)
auto insurance funding

We have had to significantly reduce the

67 (32%)
services/products we offer

Unable to hire workers at reduced wages 63 (30%)

We cannot accept new patients with auto

54 (26%)
insurance funding

We plan to close completely in the next 12

14 (7%)
months

We have had to discharge all patients with auto

11 (5%)
insurance funding

We have had to close operations completely 10 (5%)

No impact 6 (3%)

Other 60 (29%)

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Auto No-Fault Fee Change Impact Study: Phase II

Impact of the 200% reimbursement cap for Medicare payable codes

52 (25%) of the 209 organizations reported that their businesses have been impacted
by the 200% reimbursement cap for Medicare payable codes.
• 24 (50%) of the 48 organizations with data reported they were never reimbursed
at 200% of Medicare payable rates; 2 (4%) organizations reported that all their
Medicare payable claims were reimbursed at 200% of the Medicare rates.
• 37 (77%) of the 48 organizations with data reported that same Medicare payable
codes were reimbursed at inconsistent rates most of the time; 3 (6%)
organizations reported that same Medicare payable codes were reimbursed at
the same rates consistently.
• When reimbursed at less than 200% Medicare rates, the top reasons were, not a
Medicare service, multi procedure code reductions, missing/wrong form or codes,
and no charge master provided.
• When reimbursed at less than 200% Medicare rates, 33 (73%) organizations
have attempted to rebill. Of those, 11 (33%) reported never being able to recoup
the remaining balance, and 15 (45%) reported being able to recoup the balance
only up to one quarter of the time.
Percentage of claims funded by auto insurance have been paid at 200% Medicare
rates (n=48 organizations)
1 (2%)

24 14 5 2 2
(50%) (29%) (10%) (4%) (4%)

0% 1-25% 26-50% 51-75% 76-99% 100%

Frequency being reimbursed at inconsistent rate for the same Medicare payable
codes (n=48 organizations)

37 8 3
(77%) (17%) (6%)

Most of the time Occasionally Never

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Auto No-Fault Fee Change Impact Study: Phase II

Reasons for being reimbursed at less than 200% Medicare rates

(n=46 organizations)

Not a Medicare service 18 (39%)

Multi procedure code reductions 17 (37%)

Missing/wrong forms or codes 17 (37%)

No charge master provided 16 (35%)

Medicare Cascading Rule 12 (26%)

Fee exceeds Medicare MUE (Medically Unlikely

12 (26%)
Edits) limitations

Improper or overuse of modifier 59 11 (24%)

2019 charges were less than 200% of Medicare 10 (22%)

Other 14 (30%)

Percent of the time being able to recoup remaining balance when rebilled
(n=33 organizations)
1 (3%)

11 15 2 3 1
(33%) (45%) (6%) (9%) (3%)

0% of the time 1-25% of the time 26-50% of the time

51-75% of the time 76-99% of the time 100% of the time

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Auto No-Fault Fee Change Impact Study: Phase II

Impact of 55% of 2019 charges for non-payable Medicare codes

119 (57%) of the 209 organizations reported that their businesses have been impacted
by the 55% reimbursement cap of 2019 charges for non-Medicare payable codes.
• 67 (68%) organizations reported having annual profit margin no more than 20%
before July 2021 (n=99).
• Top two reasons for denial of claims were wrong codes and claim under
investigation. Other reasons for denials include not enough documentation for
services provided, services were medically unnecessary, and client had received
the maximum amount.
• 9 (8%) organizations did not experience claims denied.

Average annual profit margin prior to July 1, 2021 (n=99 organizations)

20 12 21 17 24 5
(20%) (12%) (21%) (17%) (24%) (5%)

>25% 21-25% 16-20% 11-15% 5-10% < 5%

Reasons for denial of claims (n=119 organizations)

Wrong codes 82 (69%)

Claim under investigation 67 (56%)

No charge master provided 57 (48%)

MCCA not approving services 54 (45%)

Wrong form 47 (39%)

No denials 9 (8%)

Other 32 (27%)

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Auto No-Fault Fee Change Impact Study: Phase II

Reimbursement
Respondents were asked about reimbursement for the services they provided to their
auto insurance funded patients.
• 7 (5%) have not received any reimbursement at all since July 2021 (n=140).
• 27 (19%) organizations reported having to wait for more than 120 days before
receiving any reimbursement (n=143).
• 84 organizations reported an average of 28% patients had been denied services
since July 2021 due to insurance company utilization review process, 6 of them
reported 100% of their patients have been denied services (n=84).

Proportion of claims that have not received any reimbursement since July 1, 2021
(n=140 organizations)
4 (3%)

7 11 28 70 20
(5%) (8%) (20%) (50%) (14%)

None reimbursed 76-99% not reimbursed 51-75% not reimbursed

26-50% not reimbursed 1-25% not reimbursed All reimbursed

Days to wait to receive reimbursement (n=143 organizations)

27 31 44 33 8
(19%) (22%) (31%) (23%) (6%)

> 120 days 91-120 days 61-90 days 30-60 days < 30 days

Proportion of patients denied services since July 2021 (n=84 organizations)

6 4 7 14 30 23
(7%) (5%) (8%) (17%) (36%) (27%)

100% denied 76-99% denied 51-75% denied 26-50% denied 1-25% denied 0% denied

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Auto No-Fault Fee Change Impact Study: Phase II

Working with DIFS and Insurance Adjusters

Under Michigan's auto insurance law, medical care provided to a person injured in an
auto crash must meet requirements for medical appropriateness. Auto insurers must
establish utilization review programs to make these determinations, which can be
appealed by health care providers to the Michigan Department of Insurance and
Financial Services (DIFS) Utilization Review section. Respondents were asked about
their experiences with the DIFS Utilization Review process, filing a complaint to DIFS,
and working with insurance adjusters.
• 54 organizations have filed appeals with DIFS through the Utilization Review
Process on denied services since July 1, 2021. Among the 49 reported, 36 (73%)
organizations reported that none of their appeals resulted in reinstatement of
services for their patients.
• 29 (58%) organizations reported having to wait for more than 7 weeks to get a
determination from DIFS (n=50).
• 48 organizations have filed a total of 1,284 complaints to DIFS since July 2021,
176 (14%) of the complaints were resolved in their favor.
• 92 (69%) organizations reported that their ability to productively discuss cases
with insurance adjusters has gotten worse, compared to before July 2021
(n=134).
• 69 (51%) reported having heard from insurance adjusters that the MCCA is
directing pre-approval of services and/or reimbursement (n=134).
Proportion of appeals to DIFS Utilization Review resulted in reinstatement of
services for patients (n=49 organizations)
1 (2%)

36 6 3 3
(73%) (12%) (6%) (6%)

0% 1-25% 26-50% 51-75% 76-99% 100%

Weeks to get a determination from DIFS (n=50 organizations)

19 10 13 8
(38%) (20%) (26%) (16%)

>10 business weeks 7-10 business weeks 3-6 business weeks < 3 business weeks

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Auto No-Fault Fee Change Impact Study: Phase II

Total number of complaints filed to DIFS and resolved in provider’s favor since
July 2021 (n=48 organizations)

Resolved
Total complaints filed
176
1284
(14%)

0 200 400 600 800 1000 1200 1400

Organization’s ability to productively discuss cases with insurance adjusters,

compared to before July 2021. (n=134 organizations)
4 (3%)

48 44 27 11
(36%) (33%) (20%) (8%)

Much worse Worse The same Better Much better

Respondents were asked if they have tried to contact their state representatives and/or
senators about issues resulted from the fee caps. 107 (78%) of the 136 respondents
who answered this question have tried. Of those, 67 (63%) had dialogues, 40 (37%) got
no responses.

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Auto No-Fault Fee Change Impact Study: Phase II

Provider perspectives
104 providers described in their own words what these changes meant to them.
Responses fell within the following 15 themes, accompanied by selected quotes.

Financial loss
“I had no income for six months I cannot
Providers are at a financial loss since
they are not being paid or reimbursed. hire and am working 100 + hours a week
myself due to short staffing. I lost a client
I had been caring for nine years. She
employed 32 hours a day.”
Patient discharge or discontinued
“It has been an injustice to our clients as
services
Providers have needed to discharge
they have had to be discharged from
patients, or the organizations will continue services for needs that are no longer
to lose money. being covered leaving them and their
families w/ minimal resources and
emotional upheaval.”
Aide shortages
“Finding caregivers is impossible, we are
Lack of reimbursement led to aide
shortages and burnout among staff. thankful that the handful we have
haven't left us but will when we can no
longer pay them.”
Difficulty to work with insurers
“[Insurance company] makes us use US
Providers sense that insurance
companies are putting up unnecessary mail (during pandemic) there are at least
barriers over and above the payment 25 pages per patient bill per month,
caps. many get 'lost ' and unpaid, we end up
having to retain an attorney to get paid
at all.”
Transportation shortages
“They will not pay for travel code T2003
Transportation has become problematic
and reduced, which prevents clients from
even with the charge master. They will
receiving needed therapies and care. only pay for travel code S0215 and only
pay mileage - not travel time and it is a
fight and very difficult. Most of my clients
are home bound and cannot drive”

Code confusion
“I would like to add in general there is
much more billing issues where the
billing companies coding invoices wrong,
and I have to spend a lot more time
calling insurance companies and billing
companies to try to get paid and correct
these issues.”

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Auto No-Fault Fee Change Impact Study: Phase II

Inadequate insurance or DIFS help

“To date we've received 0 communication
Providers are frustrated with the lack of
help and communication with insurance from any auto insurance carrier that
companies or DIFS, including we're waiting to be re-imbursed for
explanations regarding what services will services.”
be covered.
Unable to accept no-fault auto patients
“Since October 1, 2021, our organization
has had to stop accepting auto insurance
clients and it feels terrible to deny
services to those individuals who truly
need in-home care.”
More paperwork and longer wait
“It is more time-consuming and takes
Providers indicated they are spending
more time completing paperwork and much longer.”
waiting for payments than they did prior to
the changes.

Stress
“We are under stress and do not see
Providers face increased stress in trying
to work in the new system.
consistency in reimbursements and fear
that the insurance company will continue
to target anyone that had a contract
before the law change and leave them
destitute.”
Out of businesses
“It forced us out of business, we could not
Providers have been unable to sustain
the new changes and have had to close
find a way to absorb a 45% fee cut and
their companies altogether. provide services.”

Downsizing
“We have had to reduce staffing ratios,
Providers indicated the changes led them
to lay off staff or downsize their we cannot provide 1:1 service even
organizations to adjust for lack of though it is still needed, but the
reimbursement. reimbursement is not enough to cover
our costs for 1:1 staffing.”
Limited referrals
“The fee schedule changes have impacted
The changes have caused some
providers to have less referrals being
smaller providers by severely limiting
submitted. referrals for services. We know of other
providers in Northern Michigan that have
not had new referrals in six months, and
we have not had any new referrals in
that time either.”

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Auto No-Fault Fee Change Impact Study: Phase II

Fear for auto crash survivors’

“The client has already/previously said
transition to nursing homes
Providers indicated they did not feel auto she will run away, hitchhike somewhere,
crash survivors would transition well to dies before she lives in a home.”
living in nursing homes. Some even “Without the full no-fault reimbursement
expressed survivors would die as a result. for ALL of my daughter’s needs, she
probably would have had to be in a
nursing home, and I'm sure she would
have been neglected & abused & would
have lost her life very early on.”
Lack of company growth
“I have to turn away care constantly,
Providers indicated the changes stunted
the growth of their companies.
which affects my business growth, my
therapists, my ability to hire and the
quality of life of the patients.”

This project was funded by BIAMI.

The study was conducted by MPHI with assistance from BIAMI.

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