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:

     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 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 otherwise referred to as a non-institutional provider ,any

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

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

having primary responsibility for the care, treatment, and services provided 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 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 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 otherwise referred to as a non-institutional provider ,any

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

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

having primary responsibility for the care, treatment, and services provided 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 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,

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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 otherwise referred to as a non-institutional provider ,any

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

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

having primary responsibility for the care, treatment, and services provided 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 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 otherwise referred to as a non-institutional provider ,any

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

LC004562 - Page 3 of 4

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

having primary responsibility for the care, treatment, and services provided 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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LC004562

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE - HEALTH INSURANCE

***

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

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

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

     This act would take effect on January 1, 2015.

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LC004562

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