2013 -- H 6287

=======

LC02876

=======

STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2013

____________

A N A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

     Introduced By: Representative Robert B. Jacquard

     Date Introduced: June 26, 2013

     Referred To: House Corporations

It is enacted by the General Assembly as follows:

1-1

     SECTION 1. Section 27-18-65 of the General Laws in Chapter 27-18 entitled "Accident

1-2

and Sickness Insurance Policies" is hereby amended to read as follows:

1-3

     27-18-65. Post-payment audits. -- (a) Except as otherwise provided herein, any review,

1-4

audit or investigation by a health insurer or health plan of a health care provider's claims which

1-5

results in the recoupment or set-off of funds previously paid to the health care provider in respect

1-6

to such claims shall be completed no later than two (2) years eighteen (18) months after the

1-7

completed claims were initially paid. This section shall not restrict any review, audit or

1-8

investigation regarding claims that are submitted fraudulently, are subject to a pattern of

1-9

inappropriate billing, are related to coordination of benefits, are duplicate claims, or are subject to

1-10

any federal law or regulation that permits claims review beyond the period provided herein.

1-11

      (b) No health care provider shall seek reimbursement from a payer for underpayment of

1-12

a claim later than two (2) years eighteen (18) months from the date the first payment on the claim

1-13

was made, except if the claim is the subject of an appeal properly submitted pursuant to the

1-14

payer's claims appeal policies or the claim is subject to continual claims submission.

1-15

      (c) For the purposes of this section, "health care provider" means an individual clinician,

1-16

either in practice independently or in a group, who provides health care services, and otherwise

1-17

referred to as a non-institutional provider.

1-18

     (d) Except for those contracts where the health insurer or plan has the right to unilaterally

1-19

amend the terms of the contract, the parties shall be able to negotiate contract terms which allow

1-20

for different time frames than is prescribed herein.

2-1

     SECTION 2. Section 27-19-56 of the General Laws in Chapter 27-19 entitled "Nonprofit

2-2

Hospital Service Corporations" is hereby amended to read as follows:

2-3

     27-19-56. Post-payment audits. -- (a) Except as otherwise provided herein, any review,

2-4

audit or investigation by a nonprofit hospital service corporation of a health care provider's claims

2-5

which results in the recoupment or set-off of funds previously paid to the health care provider in

2-6

respect to such claims shall be completed no later than two (2) years eighteen (18) months after

2-7

the completed claims were initially paid. This section shall not restrict any review, audit or

2-8

investigation regarding claims that are submitted fraudulently, are subject to a pattern of

2-9

inappropriate billing, are related to coordination of benefits, are duplicate claims, or are subject to

2-10

any federal law or regulation that permits claims review beyond the period provided herein.

2-11

      (b) No health care provider shall seek reimbursement from a payer for underpayment of

2-12

a claim later than two (2) years eighteen (18) months from the date the first payment on the claim

2-13

was made, except if the claim is the subject of an appeal properly submitted pursuant to the

2-14

payer's claims appeal policies or the claim is subject to continual claims submission.

2-15

      (c) For the purposes of this section, "health care provider" means an individual clinician,

2-16

either in practice independently or in a group, who provides health care services, and otherwise

2-17

referred to as a non-institutional provider.

2-18

     (d) Except for those contracts where the health insurer or plan has the right to unilaterally

2-19

amend the terms of the contract, the parties shall be able to negotiate contract terms which allow

2-20

for different time frames than is prescribed herein.

2-21

     SECTION 3. Section 27-20-51 of the General Laws in Chapter 27-20 entitled "Nonprofit

2-22

Medical Service Corporations" is hereby amended to read as follows:

2-23

     27-20-51. Post-payment audits. -- (a) Except as otherwise provided herein, any review,

2-24

audit or investigation by a nonprofit hospital medical service corporation of a health care

2-25

provider's claims which results in the recoupment or set-off of funds previously paid to the health

2-26

care provider in respect to such claims shall be completed no later than two (2) years eighteen

2-27

(18) months after the completed claims were initially paid. This section shall not restrict any

2-28

review, audit or investigation regarding claims that are submitted fraudulently, are subject to a

2-29

pattern of inappropriate billing, are related to coordination of benefits, are duplicate claims, or are

2-30

subject to any federal law or regulation that permits claims review beyond the period provided

2-31

herein.

2-32

      (b) No health care provider shall seek reimbursement from a payer for underpayment of

2-33

a claim later than two (2) years eighteen (18) months from the date the first payment on the claim

2-34

was made, except if the claim is the subject of an appeal properly submitted pursuant to the

3-1

payer's claims appeal policies or the claim is subject to continual claims submission.

3-2

      (c) For the purposes of this section, "health care provider" means an individual clinician,

3-3

either in practice independently or in a group, who provides health care services, and otherwise

3-4

referred to as a non-institutional provider.

3-5

     (d) Except for those contracts where the health insurer or plan has the right to unilaterally

3-6

amend the terms of the contract, the parties shall be able to negotiate contract terms which allow

3-7

for different time frames than is prescribed herein.

3-8

     SECTION 4. Section 27-41-69 of the General Laws in Chapter 27-41 entitled "Health

3-9

Maintenance Organizations" is hereby amended to read as follows:

3-10

     27-41-69. Post-payment audits. -- (a) Except as otherwise provided herein, any review,

3-11

audit or investigation by a health maintenance organization of a health care provider's claims

3-12

which results in the recoupment or set-off of funds previously paid to the health care provider in

3-13

respect to such claims shall be completed no later than two (2) years eighteen (18) months after

3-14

the completed claims were initially paid. This section shall not restrict any review, audit or

3-15

investigation regarding claims that are submitted fraudulently, are subject to a pattern of

3-16

inappropriate billing, are related to coordination of benefits, are duplicate claims, or are subject to

3-17

any federal law or regulation that permits claims review beyond the period provided herein.

3-18

      (b) No health care provider shall seek reimbursement from a payer for underpayment of

3-19

a claim later than two (2) years eighteen (18) months from the date the first payment on the claim

3-20

was made, except if the claim is the subject of an appeal properly submitted pursuant to the

3-21

payer's claims appeal policies or the claim is subject to continual claims submission.

3-22

      (c) For the purposes of this section, "health care provider" means an individual clinician,

3-23

either in practice independently or in a group, who provides health care services, and otherwise

3-24

referred to as a non-institutional provider.

3-25

     (d) Except for those contracts where the health insurer or plan has the right to unilaterally

3-26

amend the terms of the contract, the parties shall be able to negotiate contract terms which allow

3-27

for different time frames than is prescribed herein.

3-28

     SECTION 5. This act shall take effect on January 1, 2014.

=======

LC02876

========

EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

***

4-1

     This act would amend the amount of time permitted for a health payer to conduct a post-

4-2

payment audit from two (2) years to eighteen (18) months and would establish an appeals process

4-3

prior to any recoupment or set-off. It would also allow the parties to health insurance plans to

4-4

negotiate different time frames than specified herein.

4-5

     This act would take effect on January 1, 2014.

=======

LC02876

=======