Medical Billing for Functional Medicine
in Michigan

Payment and Coverage-Parity Statutes

• HB 4579 & HB 4131 (2024) ensure full payment parity between telemedicine and in-person services for all licensed insurers and HMOs. Plans can no longer pay 80 percent of the office rate for video visits.
• HB 4580 (Public Act 53) requires Medicaid and the Healthy Michigan Program to value audio-only encounters at the same rate as video or in-person visits when broadband gaps exist.

Medicaid (MDHHS) Telemedicine Guide – January 2025 Update

• Recognizes POS 02 (other location) and POS 10 (patient home).
• Requires modifier 95 for synchronous video, modifier FQ for audio-only.
• Clinics can bill group visits and remote monitoring if procedure codes appear on the “Clinic Reimbursement List.”

Enforcement & Documentation

Michigan’s Office of Inspector General (OIG) audits telehealth charts for:

• Signed consent;
• Start/stop times;
• Location of patient and provider;
• Attestation of broadband or technology barrier for audio-only.

DelonHealth’s telehealth template embeds these checks to keep you compliant.

DelonHealth hard-codes each plan’s PA list, frequency edits, and telehealth modifier rules into our claim-scrubber—pushing clean-claim rates above 96 percent for Michigan FM clinics.

Medicaid / CHAMPS

• Enroll through CHAMPS; choose taxonomy 2254P0008X (functional medicine) or a conventional specialty plus integrative focus.
• Upload telemedicine training attestation; CHAMPS flags audio-only parity.
• Revalidate every five years; dashboard reminders appear 120 days in advance.

Managed-Care Contracts

• BCBS Complete, Molina, and Meridian send separate addenda after state enrollment; DelonHealth tracks every effective date in our contract calendar.
• Priority Health negotiates via its Provider Contract Portal; plan for 90–120 days.

Commercial

Blue Cross and HAP use CAQH ProView; attest data every quarter. Ask that prolonged-service 99417, group-visit G0511, and lifestyle-medicine Category III suite 0591T–0593T be carved into fee schedules.

DelonHealth’s Credentialing Desk handles CAQH, CHAMPS revalidation, EFT, and W-9 paperwork, eliminating the 40-plus administrative hours most clinics spend each year.

DelonHealth is an RCM partner; we do not provide formal CPT coding services. Your coding team retains full responsibility for code selection, while we handle claim-scrubbing, submission, and denial recovery.

Our claim-scrubber cross-checks each service against payer-specific PA matrices and telehealth requirements before a claim leaves your EHR.

High-Scrutiny Diagnostics

• Comprehensive stool microbiome (> 20 analytes)
• Nutrigenomic panels (MTHFR, COMT, GSTM1, APOE)
• Organic-acid tests (OAT)
• High-dose IV vitamin therapies

Winning PA Elements

• Clear ICD-10 linkage (e.g., K58.0 IBS → stool panel).
• Peer-review citations (PubMed IDs).
• Prior treatment failures (e.g., negative colonoscopy, persistent dysbiosis).
• Statement of how results will change management (e.g., probiotic tailoring).

DelonHealth’s PA Unit pre-loads these data into eviCore, Priority Health, CoverMyMeds, or JIVA portals, achieving a 97 percent approval rate.

• ROOT-CAUSE macro—Reason, Objective findings, Origin analysis, Treatment plan, Counseling minutes, Assessment (ICD-10), Utilization rationale, Supplement regimen, Effectiveness metrics.
• Telehealth charting—capture start/stop times, technology platform, patient location, provider location, barrier attestation for audio-only.
• ABNs & GFEs—store in EHR meta data; Michigan OIG requests them during desk audits.

DelonHealth audits 10 charts/provider quarterly, delivering a Corrective-Action Plan and CME links.

Michigan law currently addresses surprise billing in hospital and emergency scenarios but allows direct-pay memberships or hybrid models for outpatient clinics.

Successful FM revenue mixes include:

• Memberships covering unlimited health-coaching, supplement discounts, and sauna access.
• Superbills for out-of-network BCBS PPO members.
• HSA-qualified lab bundles flagged as IRS § 213(d) expenses.
• Good-Faith Estimates (GFEs) for non-covered advanced labs to comply with the federal No Surprises Act.

DelonHealth configures your PM system to track membership revenue separately, ensuring transparent audits.

A two-provider FM practice with 65 weekly visits and 45 percent BCBSM mix.

Problem – 28 percent denial rate, 74 days A/R, provider exhaustion from PA admin.

Delon Intervention – eviCore genetic PA templates, telehealth macro with audio-only attestation, membership ledger segregation.

Six-Month Results

• Denials: 3.9 percent
• A/R: 24 days
• Revenue per visit: +18 percent
• Providers gained 8 clinical hours per week

Solo RDN with high Priority Health and Medicaid panels.

Problem – Rejected MNT claims, unclear telehealth modifiers.

Delon Intervention – Embedded FQ modifier defaults, uploaded CHAMPS telehealth attestation, automated PA for stool panels.

Four-Month Results

• Paid-claim ratio: 98 percent
• Cash supplement revenue: +$5,000 monthly

Front-End

• Real-time eligibility checks via CHAMPS, Availity, and Priority Health portals.
• Automated prior-authorization uploads to eviCore, JIVA, and CoverMyMeds.
• Good-Faith Estimate generator that aligns with No Surprises Act.

Mid-Cycle

• AI claim-scrubbing against BCBSM molecular policies, Priority digestive-marker edits, and Medicaid telehealth modifiers.
• Quarterly chart audits with CME webinars.

Back-End

• 24-hour claim submission and 835 auto-posting.
• Weekly A/R sweeps and Denial-Recovery escalation to DIFS.

Strategic Services

• Fee-schedule benchmarking vs. CMS Detroit wage index.
• Value-based contract negotiation with BCBSM PCMH and Mi-PCT.
• Monthly legislative brief—HB 4579/4131 updates, Medicaid bulletin MMP-25-06 code changes.

Next Steps

• Visit delonhealth.com/functional-medicine-rcm.
• Schedule a complimentary 30-minute revenue-cycle assessment.
• Receive a customized payer-edit heatmap for your Michigan ZIP code.