No-fault personal protection insurance (PIP) benefits; Healthcare providers’ claims for reimbursement for medical services provided to an insured; Reimbursement cap in MCL 500.3157(2)(b); Favot v Brown; Definition of “Medicare” in MCL 500.3157(15)(f)

In this action by plaintiffs-healthcare providers for PIP benefits for services provided to defendant’s insured, the court concluded it was clear the trial court’s ruling denying defendant’s summary disposition motion “was based on an incorrect interpretation of MCL 500.3157, as it did not apply the full Medicare payment methodology now required by Favot.” Defendant argued the trial court erred in “denying its motion for summary disposition under MCR 2.116(C)(7) and (C)(10).” It contended that amendments clearly indicated “the Legislature intended for Medicare payment methodologies to be incorporated into” the No-Fault Act. Defendant asserted “the Medicare rate limitations and adjustments related to the Medicare fee schedule rates apply to claims for no-fault PIP benefits.” It additionally contended “that it paid plaintiffs what they were owed—that is, 195% of what Medicare would pay for the applicable services. In light of” its recent ruling in Favot, the court agreed in part. Under Favot, “insurers must apply all Medicare payment methodologies that are related to the rates in the fee schedule. Only those limitations that are expressly ‘unrelated to the rates in the fee schedule’ are excluded from consideration.” The court concluded that questions remained here as to the specific amounts owed. “On remand, the correct reimbursement cap under MCL 500.3157(2) must be calculated by applying the full Medicare payment methodology, including all rate-related adjustments, reductions, and bundling rules, except for those limitations expressly excluded, consistent with Favot.” Affirmed in part, reversed in part, and remanded.