2017 -- S 0497 SUBSTITUTE A

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LC001759/SUB A/3

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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: Senators Lynch Prata, and Doyle

     Date Introduced: March 02, 2017

     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.

     (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 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 known or should have been known by the health

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

billing of their respective medical or dental specialties; 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 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 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.

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

hospital service corporation of a health-care provider's claims 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 known or should have been known

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

provider billing of their respective medical or dental specialties; 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 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 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 that 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.

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

medical service corporation of a health care provider's claims 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 known or should have been known

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

provider billing of their respective medical or dental specialties; 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 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.

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

maintenance organization of a health care provider's claims 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 known or should have been known

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

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

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

LC001759/SUB A/3 - Page 3 of 5

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

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

     27-20.1-19. Post-payment audits.

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

dental 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 two (2) years 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 known or should have been known by the health

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

billing of their respective medical or dental specialty, are related to coordination of benefits, 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 two (2) years 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.

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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

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

     This act would take effect upon passage.

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