2017 -- H 5634 SUBSTITUTE B

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LC001663/SUB B

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2017

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A N   A C T

RELATING TO INSURANCE ACCIDENT AND SICKNESS INSURANCE POLICIES

     

     Introduced By: Representative Scott Slater

     Date Introduced: March 01, 2017

     Referred To: House Corporations

     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.

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     (a) Except as otherwise provided herein, any review, audit or investigation by a health

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insurer or health plan of a health care provider's claims that results in the recoupment or set-off of

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funds previously paid to the health care provider in respect to such claims shall be completed no

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later than eighteen (18) months after the completed claims were initially paid. This section shall

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not restrict any review, audit, or investigation regarding claims that are submitted fraudulently;

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are subject to a pattern of inappropriate billing known or should have been known by the health

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care provider to be a pattern of inappropriate billing according to the standards for provider

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billing of their respective medical or dental specialties; are related to coordination of benefits; are

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duplicate claims; or are subject to any federal law or regulation that permits claims review

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beyond the period provided herein.

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

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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 any

 

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healthcare 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 practitioner as identified to the review agent as

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

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

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

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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.

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     (a) Except as otherwise provided herein, any review, audit or investigation by a nonprofit

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hospital service corporation of a health-care provider's claims that results in the recoupment or

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set-off of funds previously paid to the health-care provider in respect to such claims shall be

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completed no later than eighteen (18) months after the completed claims were initially paid. This

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section shall not restrict any review, audit, or investigation regarding claims that are submitted

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fraudulently; are subject to a pattern of inappropriate billing known or should have been known

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by the health care provider to be a pattern of inappropriate billing according to the standards for

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provider billing of their respective medical or dental specialties; are related to coordination of

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benefits; are duplicate claims; or are subject to any federal law or regulation that permits claims

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review beyond the period provided herein.

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

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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 any

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healthcare 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 practitioner identified to the review agent as having

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

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

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

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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.

 

LC001663/SUB B - Page 2 of 6

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     (a) Except as otherwise provided herein, any review, audit or investigation by a nonprofit

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medical service corporation of a health care provider's claims that results in the recoupment or

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set-off of funds previously paid to the health care provider in respect to such claims shall be

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completed no later than eighteen (18) months after the completed claims were initially paid. This

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section shall not restrict any review, audit, or investigation regarding claims that are submitted

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fraudulently; are subject to a pattern of inappropriate billing known or should have been known

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by the health care provider to be a pattern of inappropriate billing according to the standards for

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provider billing of their respective medical or dental specialties; are related to coordination of

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benefits; are duplicate claims; or are subject to any federal law or regulation that permits claims

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review beyond the period provided herein.

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

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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 any

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healthcare facility, as defined in § 27-20-1 including any mental health and/or substance abuse

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treatment facility, physician, or other licensed practitioner identified to the review agent as having

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

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

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

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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.

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     (a) Except as otherwise provided herein, any review, audit or investigation by a health

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maintenance organization of a health care provider's claims that results in the recoupment or set-

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off of funds previously paid to the health care provider in respect to such claims shall be

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completed no later than eighteen (18) months after the completed claims were initially paid. This

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section shall not restrict any review, audit, or investigation regarding claims that are submitted

31

fraudulently; are subject to a pattern of inappropriate billing known or should have been known

32

by the health care provider to be a pattern of inappropriate billing according to the standards for

33

provider billing of their respective medical or dental specialties; are related to coordination of

34

benefits; are duplicate claims; or are subject to any federal law or regulation that permits claims

 

LC001663/SUB B - Page 3 of 6

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review beyond the period provided herein.

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

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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 any

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healthcare facility, as defined in § 27-41-2 including any mental health and/or substance abuse

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treatment facility, physician, or other licensed practitioner identified to the review agent as having

10

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

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

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

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for different time frames than is prescribed herein.

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     SECTION 5. Section 27-20.1-19 of the General Laws in Chapter 27-20.1 entitled

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"Nonprofit Dental Service Corporations" is hereby amended to read as follows:

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     27-20.1-19. Post-payment audits.

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     (a) Except as otherwise provided herein, any review, audit or investigation by a nonprofit

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dental service corporation of a health care provider's claims which results in the recoupment or

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set-off of funds previously paid to the health care provider in respect to such claims shall be

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completed no later than two (2) years eighteen (18) months after the completed claims were

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initially paid. This section shall not restrict any review, audit or investigation regarding claims

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that are submitted fraudulently, are subject to known or should have been known by the health

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care provider to be a pattern of inappropriate billing according to the standards for provider

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billing of their respective medical or dental specialty, are related to coordination of benefits, or

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

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herein.

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

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

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

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payer's claims 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.

 

LC001663/SUB B - Page 4 of 6

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     SECTION 6. This act shall take effect upon passage.

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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 permit an audit or claims investigation for a pattern of inappropriate

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billing only if it is determined that the claims are known by the provider to be inappropriate.

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     This act would take effect upon passage.

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LC001663/SUB B

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LC001663/SUB B - Page 6 of 6