2014 -- S 2536

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LC004562

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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 - HEALTH INSURANCE

     

     Introduced By: Senator Gayle L.Goldin

     Date Introduced: February 27, 2014

     Referred To: Senate Health & Human Services

     It is enacted by the General Assembly as follows:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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referred to as a non-institutional provider otherwise referred to as a non-institutional provider ,any

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health care facility as defined in § 27-18-1.1, including any mental health and/or substance abuse

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treatment facility, physician, or other licensed practitioners as identified by a review agent as

 

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having primary responsibility for the care, treatment, and services provided to a patient.

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

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

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which allow for different time frames than is prescribed herein.

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

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

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

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

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

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

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

12

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

13

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

14

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

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

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

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

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

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

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

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referred to as a non-institutional provider otherwise referred to as a non-institutional provider ,any

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health care facility as defined in § 27-18-1.1, including any mental health and/or substance abuse

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treatment facility, physician, or other licensed practitioners as identified by a review agent as

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having primary responsibility for the care, treatment, and services provided to a patient.

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

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

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which allow for different time frames than is prescribed herein.

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

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

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

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

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

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

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

 

LC004562 - Page 2 of 4

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

2

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

3

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

4

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

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

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

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

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

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

10

referred to as a non-institutional provider otherwise referred to as a non-institutional provider ,any

11

health care facility as defined in § 27-18-1.1, including any mental health and/or substance abuse

12

treatment facility, physician, or other licensed practitioners as identified by a review agent as

13

having primary responsibility for the care, treatment, and services provided to a patient.

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

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

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which allow for different time frames than is prescribed herein.

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

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Maintenance Organizations" is hereby amended to read as follows:

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

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

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

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

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

24

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

25

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

26

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

27

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

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

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

30

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

31

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

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

33

referred to as a non-institutional provider otherwise referred to as a non-institutional provider ,any

34

health care facility as defined in § 27-18-1.1, including any mental health and/or substance abuse

 

LC004562 - Page 3 of 4

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treatment facility, physician, or other licensed practitioners as identified by a review agent as

2

having primary responsibility for the care, treatment, and services provided to a patient.

3

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

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

5

which allow for different time frames than is prescribed herein.

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     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 - HEALTH INSURANCE

***

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     This act would redefine health care providers as identified by a review agent as having

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primary responsibility for the care, treatment, and services provided to a patient and would

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include mental health and/or substance abuse treatment facilities and physicians.

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     This act would take effect on January 1, 2015.

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LC004562

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