Updates from Michigan Health Plans: Policies and Strategies Affecting Healthcare Delivery
The Michigan State Medical Society's Health Care Delivery Department has received updates from various Michigan health plans and insurers regarding their latest policies, programs, and educational opportunities relevant to healthcare providers. These updates aim to enhance the efficiency and effectiveness of healthcare delivery for providers and patients alike.
The Centers for Medicare & Medicaid Services (CMS) have proposed a rule for 2026 focusing on Interoperability Standards and Prior Authorization for Drugs (CMS-0062-P). This directive seeks to improve transparency in prior authorizations, necessitating electronic submissions and rapid responses. This proposal builds on prior rules and mandates the use of standardized APIs. Additionally, under HIPAA, the Department of Health and Human Services encourages adopting FHIR-based standards for prior authorization transactions. Public commentary on this proposal is open until June 15, 2026.
CMS has also introduced a new Behavioral Health Strategy aimed at providing accessible and high-value services. This strategy underscores the importance of integrative care, focusing on early prevention and health promotion, especially for children and adolescents. CMS is committed to evidence-based care through value-based payment models and is collaborating with providers and government entities to achieve a lasting impact.
In other developments, McLaren Health Plan's audit revealed discrepancies in claim reimbursements with Michigan Department of Health and Human Services (MDHHS) guidelines. To rectify this, a reprocessing initiative is set for FQHCs, RHCs, and THCs, with providers receiving outreach for recoupment starting in mid-June 2026. This initiative aligns with Medicaid billing regulations to ensure compliance and accuracy.
The Health Alliance Plan (HAP) advises adherence to specific guidelines for professional claims exceeding $99,999.99. HAP collaborates with vendors such as Optum/Episource, LLC, and Cognisight to conduct medical record reviews, contacting provider offices directly. Cooperation is essential as lack of response may result in claim recoveries, although HAP aims to minimize patient care disruptions.
Additionally, Meridian Health Plan is launching its annual provider satisfaction survey in April 2026 to gather valuable feedback for improvement initiatives. Providers affiliated with Blue Cross Blue Shield of Michigan are reminded to regularly audit access permissions in Availity Essentials to protect health information. Advanced practice providers will have access to Health e-Blue tools, excluding Blue Care Network, with support available from BCBSM or Availity for any access issues.
Members of the Michigan State Medical Society with billing inquiries can contact Dara Barrera for assistance. The MSMS Physicians Insurance Agency offers tailored insurance solutions, while PCVS provides credentialing services across the healthcare spectrum. Engaging in legislative involvement, the society sponsors a bipartisan political action committee to support the medical profession.