2022 -- H 7344 SUBSTITUTE A

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LC004478/SUB A

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2022

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A N   A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

     Introduced By: Representative Brandon C. Potter

     Date Introduced: February 04, 2022

     Referred To: House 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 healthcare provider's claims that results in the recoupment or set-off of

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

later than eighteen (18) months after the completed claims were initially paid, except that the period

for recoupment or set-off for claims submitted by a mental health and/or substance use disorder

provider, for those services, licensed by this state, and participating with the health insurer or health

plan, shall be no later than twelve (12) months. This section shall not restrict any review, audit, or

investigation regarding claims that are submitted fraudulently; are known, or should have been

known, by the healthcare 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 healthcare 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, "healthcare provider" means an individual clinician,

either in practice independently or in a group, who provides healthcare 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 healthcare provider's claims that results in the recoupment or set-

off of funds previously paid to the healthcare provider in respect to such claims shall be completed

no later than eighteen (18) months after the completed claims were initially paid, except that the

period for recoupment or set-off for claims submitted by a mental health and/or substance use

disorder provider, for those services, licensed by this state, and participating with the health insurer

or health plan, shall be no later than twelve (12) months. This section shall not restrict any review,

audit, or investigation regarding claims that are submitted fraudulently; are known, or should have

been known, by the healthcare 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 healthcare 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, "healthcare provider" means an individual clinician,

either in practice independently or in a group, who provides healthcare 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

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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.

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

medical service corporation of a healthcare provider's claims that results in the recoupment or set-

off of funds previously paid to the healthcare provider in respect to such claims shall be completed

no later than eighteen (18) months after the completed claims were initially paid, except that the

period for recoupment or set-off for claims submitted by a mental health and/or substance use

disorder provider, for those services, licensed by this state, and participating with the health insurer

or health plan, shall be no later than twelve (12) months. This section shall not restrict any review,

audit, or investigation regarding claims that are submitted fraudulently; are known, or should have

been known, by the healthcare 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 healthcare 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, "healthcare provider" means an individual clinician,

either in practice independently or in a group, who provides healthcare 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 healthcare provider's claims that results in the recoupment or set-off

of funds previously paid to the healthcare provider in respect to such claims shall be completed no

LC004478/SUB A - Page 3 of 5

later than eighteen (18) months after the completed claims were initially paid, except that the period

for recoupment or set-off for claims submitted by a mental health and/or substance use disorder

provider, for those services, licensed by this state, and participating with the health insurer or health

plan, shall be no later than twelve (12) months. This section shall not restrict any review, audit, or

investigation regarding claims that are submitted fraudulently; are known, or should have been

known, by the healthcare 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 healthcare 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, "healthcare provider" means an individual clinician,

either in practice independently or in a group, who provides healthcare 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. 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

***

     This act would provide that the period for health insurance providers to seed recoupment

or set-off for claims submitted by a mental health and/or substance use disorder provider, would be

reduced from eighteen months to not more than twelve (12) months.

     This act would take effect upon passage.

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