2014 -- H 7790 SUBSTITUTE A

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LC005028/SUB A

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2014

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A N   A C T

RELATING TO INSURANCE - ACCIDENT AND SICKNESS INSURANCE POLICIES

     Introduced By: Representative Robert B.Jacquard

     Date Introduced: March 04, 2014

     Referred To: House Corporations

     It is enacted by the General Assembly as follows:

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

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

     27-18-65. Post-payment audits. [Effective January 1, 2014.] -- (a) Except as otherwise

provided herein, any review, audit or investigation by a health insurer or health plan of a health

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

the health care provider in respect to such claims shall be completed no later than eighteen (18)

months after the completed claims were initially paid. This section shall not restrict any review,

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

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

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

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

a claim later than eighteen (18) months from the date the first payment on the claim was made,

except if the claim is the subject of an appeal properly submitted pursuant to the payer's claims

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

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

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

referred to as a non-institutional provider any healthcare facility, as defined in § 27-18-1.1

including any mental health and/or substance abuse treatment facility, physician, or other licensed

practitioner as identified to the review agent as having primary responsibility for the care,

treatment, and services rendered to a patient.

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

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

which that allow for different time frames than is prescribed herein.

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

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

     27-19-56. Post-payment audits. [Effective January 1, 2014.] -- (a) Except as otherwise

provided herein, any review, audit or investigation by a nonprofit hospital service corporation of a

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

paid to the health care provider in respect to such claims shall be completed no later than eighteen

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

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

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

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

herein.

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

a claim later than eighteen (18) months from the date the first payment on the claim was made,

except if the claim is the subject of an appeal properly submitted pursuant to the payer's claims

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

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

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

referred to as a non-institutional provider any healthcare facility, as defined in § 27-19-1

including any mental health and/or substance abuse treatment facility, physician, or other licensed

practitioner identified to the review agent as having primary responsibility for the care, treatment,

and services rendered to a patient.

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

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

which allow for different time frames than is prescribed herein.

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

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

     27-20-51. Post-payment audits. [Effective January 1, 2014.] -- (a) Except as otherwise

provided herein, any review, audit or investigation by a nonprofit medical service corporation of a

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

paid to the health care provider in respect to such claims shall be completed no later than eighteen

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

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

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

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

herein.

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

a claim later than eighteen (18) months from the date the first payment on the claim was made,

except if the claim is the subject of an appeal properly submitted pursuant to the payer's claims

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

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

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

referred to as a non-institutional provider any healthcare facility, as defined in § 27-20-1

including any mental health and/or substance abuse treatment facility, physician, or other licensed

practitioner identified to the review agent as having primary responsibility for the care, treatment,

and services rendered to a patient.

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

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

which allow for different time frames than is prescribed herein.

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

Maintenance Organizations" is hereby amended to read as follows:

     27-41-69. Post-payment audits. [Effective January 1, 2014.] -- (a) Except as otherwise

provided herein, any review, audit or investigation by a health maintenance organization of a

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

paid to the health care provider in respect to such claims shall be completed no later than eighteen

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

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

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

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

herein.

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

a claim later than eighteen (18) months from the date the first payment on the claim was made,

except if the claim is the subject of an appeal properly submitted pursuant to the payer's claims

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

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

LC005028/SUB A - Page 3 of 5

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

referred to as a non-institutional provider any healthcare facility, as defined in § 27-41-2

including any mental health and/or substance abuse treatment facility, physician, or other licensed

practitioner identified to the review agent as having primary responsibility for the care, treatment,

and services rendered to a patient.

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

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

which allow for different time frames than is prescribed herein.

     SECTION 5. This act shall take effect on January 1, 2015.

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE - ACCIDENT AND SICKNESS INSURANCE POLICIES

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     This act would expand the definition of "healthcare provider" to include healthcare

facility that treat patients for mental health and/or substance abuse as well as physicians or other

licensed practitioners responsible for care, treatment and services to patients for the purpose of

post-payment audits.

     This act would take effect on January 1, 2015.

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