The No-Fault Act (NFA); PIP benefits; Limitations related to the rates in Medicare’s no-fault fee schedule; MCL 500.3157; Central Home Health Care Servs, Inc v Progressive MI Ins Co; “Medicare”; MCL 500.3157(15)(f); Multiple-procedure payment reduction rule (MPPR)

The court concluded “that the trial court erred by denying defendant’s [insurer] motion for partial summary disposition under MCR 2.116(C)(10), because no genuine issue of material fact existed concerning whether defendant could apply limitations related to the rates in the fee schedule.” But it held that “because application of the related limitations and reductions affect[ed] the amount payable by Medicare, and, as a result, what defendant must pay, factual questions still” remained. As such, “summary disposition under MCR 2.116(C)(7) was not appropriate, and the trial court did not err by denying defendant’s motion for partial summary disposition on those grounds.” Plaintiff was injured in a motor vehicle accident. Defendant claimed “there was no genuine issue of material fact that MCL 500.3157 authorized it to apply limitations related to the rates in Medicare’s no-fault fee schedule when determining the amount payable.” It also argued “that it properly paid plaintiff’s claims.” The court agreed, in part. The parties disagreed “about whether MCL 500.3157(15)(f) allows defendant to apply certain limitations, reductions, and adjustments when determining the amount payable to plaintiff’s medical providers. The specific interpretation at issue here involves whether defendant may apply the packaged-service rule, the MPPR, or billing modifiers, that Medicare utilizes when determining the amount payable to providers.” Defendant contended “that these limitations may be applied because they are related to the rates in the Medicare fee schedule.” Plaintiff construed “MCL 500.3157(15)(f) differently.” He contended “that these particular limitations are unrelated to, and, therefore, cannot be used to reduce the amount owed to plaintiff’s medical providers.” The court concluded that under “Central Home, the amount payable by insurers are not determined by the rates in the fee schedule alone, but also by applying limitations related to the rates in the fee schedule.” The question before the court was “whether the limitations defendant seeks to apply are ‘of the same kind, class, character, or nature’ as the unrelated limitations listed in MCL 500.3157(15)(f).” The court found that “the limitations defendant applied here are related to the fee schedule. Defendant used the rates in the fee schedule to determine an initial payment amount, then adjusted the rates in the fee schedules to determine the amount payable by Medicare under MCL 500.3157(2) and (7) by applying the MPPR, packaged-service rule, and geographical billing modifier. Because these limitations and reductions are related to the fee schedule, they are not of the same kind, class, character, or nature as those prohibited by MCL 500.3157(15)(f).” Thus, the court found that “under the plain language of MCL 500.3157(2)(a), limitations such as the MPPR, the packaged-service rule, and the geographic billing modifier affect the amount Medicare would pay for the particular service, meaning they may be considered for purposes of the” NFA. Affirmed in part, reversed in part, and remanded.