2013 -- S 0536

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LC01274

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STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2013

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A N A C T

RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES

     Introduced By: Senators Goldin, Cool Rumsey, Conley, Satchell, and Sosnowski

     Date Introduced: February 28, 2013

     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. -- (a)(1) Except as otherwise provided herein, any

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review, audit or investigation by a health insurer or health plan of a health care provider's claims

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

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respect to such claims shall be completed no later than two (2) years one year after the completed

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claims were initially paid.

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     (2) No funds previously paid to the health care provider shall be recouped or set-off by

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the health insurer or health plan until the health care provider shall have received sixty (60) days'

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written notice of the health insurer's or health plan's proposed recoupment or set-off activities and

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an opportunity to appeal such action. The written notice shall include:

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     (i) The principal reasons for the recoupment or set-off, including documentation

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supporting the health insurer's or health plan's actions;

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     (ii) The procedures to initiate an appeal of the recoupment or set-off, including the name

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and telephone number of the person to contact with regard to an appeal.

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     (3) The health insurer or health plan shall notify the health care provider of its decision

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on the appeal as soon as practical, but in no case later than fifteen (15) calendar days after

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receiving written or electronic notice of the health care provider's desire to appeal.

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     (4) In cases where the internal appeal is unsuccessful, the health insurer or health plan

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shall provide for an external appeal by an unrelated and objective independent public auditor.

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     (5) This section shall not restrict any review, audit or investigation regarding claims that

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are submitted fraudulently, are subject to a pattern of inappropriate billing, are related to

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coordination of benefits, 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

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a claim later than two (2) years one year 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.

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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. -- (a)(1) Except as otherwise provided herein, any

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review, audit or investigation by a nonprofit hospital service corporation of a health care

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

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care provider in respect to such claims shall be completed no later than two (2) years one year

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after the completed claims were initially paid.

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     (2) No funds previously paid to the health care provider shall be recouped or set-off by

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the nonprofit hospital service corporation until the health care provider shall have received sixty

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(60) days' written notice of the nonprofit hospital service corporation's proposed recoupment or

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set-off activities and an opportunity to appeal such action. The written notice shall include:

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     (i) The principal reasons for the recoupment or set-off, including documentation

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supporting the nonprofit hospital service corporation's actions;

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     (ii) The procedures to initiate an appeal of the recoupment or set-off, including the name

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and telephone number of the person to contact with regard to an appeal.

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     (3) The nonprofit hospital service corporation shall notify the health care provider of its

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decision on the appeal as soon as practical, but in no case later than fifteen (15) calendar days

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after receiving written or electronic notice of the health care provider's desire to appeal.

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     (4) In cases where the internal appeal is unsuccessful, nonprofit hospital service

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corporation shall provide for an external appeal by an unrelated and objective independent public

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auditor.

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     (5) This section shall not restrict any review, audit or investigation regarding claims that

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are submitted fraudulently, are subject to a pattern of inappropriate billing, are related to

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coordination of benefits, 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

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a claim later than two (2) years one year 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.

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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. -- (a)(1) Except as otherwise provided herein, any

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review, audit or investigation by a nonprofit hospital medical service corporation of a health care

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

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care provider in respect to such claims shall be completed no later than two (2) years one year

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after the completed claims were initially paid.

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     (2) No funds previously paid to the health care provider shall be recouped or set-off by

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the nonprofit hospital service corporation until the health care provider shall have received sixty

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(60) days' written notice of the health insurer's or health plan's proposed recoupment or set-off

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activities and an opportunity to appeal such action. The written notice shall include:

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     (i) The principal reasons for the recoupment or set-off, including documentation

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supporting the nonprofit hospital service corporation's actions;

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     (ii) The procedures to initiate an appeal of the recoupment or set-off, including the name

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and telephone number of the person to contact with regard to an appeal.

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     (3) The nonprofit hospital service corporation shall notify the health care provider of its

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decision on the appeal as soon as practical, but in no case later than fifteen (15) calendar days

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after receiving written or electronic notice of the health care provider's desire to appeal.

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     (4) In cases where the internal appeal is unsuccessful, the nonprofit hospital service

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corporation shall provide for an external appeal by an unrelated and objective independent public

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auditor.

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     (2) No funds previously paid to the health care provider shall be recouped or set-off by

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the nonprofit hospital service corporation until the health care provider shall have received sixty

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(60) days' written notice of the health insurer's or health plan's proposed recoupment or set-off

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activities and an opportunity to appeal such action. The written notice shall include:

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     (i) The principal reasons for the recoupment or set-off, including documentation

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supporting the health insurer's or health plan's actions;

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     (ii) The procedures to initiate an appeal of the recoupment or set-off, including the name

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and telephone number of the person to contact with regard to an appeal.

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     (3) The nonprofit hospital service corporation shall notify the health care provider of its

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decision on the appeal as soon as practical, but in no case later than fifteen (15) calendar days

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after receiving written or electronic notice of the health care provider's desire to appeal.

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     (4) In cases where the internal appeal is unsuccessful, nonprofit hospital service

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corporation shall provide for an external appeal by an unrelated and objective independent public

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auditor.

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     (5) This section shall not restrict any review, audit or investigation regarding claims that

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are submitted fraudulently, are subject to a pattern of inappropriate billing, are related to

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coordination of benefits, 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

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a claim later than two (2) years one year 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.

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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. -- (a)(1) Except as otherwise provided herein, any

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review, audit or investigation by a health maintenance organization of a health care provider's

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

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provider in respect to such claims shall be completed no later than two (2) years one year after the

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completed claims were initially paid.

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     (2) No funds previously paid to the health care provider shall be recouped or set-off by

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the nonprofit hospital service corporation until the health care provider shall have received sixty

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(60) days' written notice of the nonprofit hospital service corporation's proposed recoupment or

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set-off activities and an opportunity to appeal such action. The written notice shall include:

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     (i) The principal reasons for the recoupment or set-off, including documentation

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supporting the nonprofit hospital service corporation's actions;

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     (ii) The procedures to initiate an appeal of the recoupment or set-off, including the name

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and telephone number of the person to contact with regard to an appeal.

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     (3) The nonprofit hospital service corporation shall notify the health care provider of its

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decision on the appeal as soon as practical, but in no case later than fifteen (15) calendar days

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after receiving written or electronic notice of the health care provider's desire to appeal.

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     (4) In cases where the internal appeal is unsuccessful, the nonprofit hospital service

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corporation shall provide for an external appeal by an unrelated and objective independent public

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auditor.

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     (2) No funds previously paid to the health care provider shall be recouped or set-off by

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the nonprofit hospital service corporation until the health care provider shall have received sixty

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(60) days' written notice of the nonprofit hospital service corporation's proposed recoupment or

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set-off activities and an opportunity to appeal such action. The written notice shall include:

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     (i) The principal reasons for the recoupment or set-off, including documentation

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supporting the health insurer's or health plan's actions;

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     (ii) The procedures to initiate an appeal of the recoupment or set-off, including the name

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and telephone number of the person to contact with regard to an appeal.

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     (3) The nonprofit hospital service corporation shall notify the health care provider of its

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decision on the appeal as soon as practical, but in no case later than fifteen (15) calendar days

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after receiving written or electronic notice of the health care provider's desire to appeal.

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     (4) In cases where the internal appeal is unsuccessful, the health insurer or health plan

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shall provide for an external appeal by an unrelated and objective independent public auditor.

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     (5) This section shall not restrict any review, audit or investigation regarding claims that

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are submitted fraudulently, are subject to a pattern of inappropriate billing, are related to

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coordination of benefits, 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

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a claim later than two (2) years one year 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.

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SECTION 5. This act shall take effect upon passage.

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LC01274

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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 amend the amount of time permitted for a health payer to conduct a post-

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payment audit from two (2) years to one year and would establish an appeals process prior to any

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recoupment or set-off.

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     This act would take effect upon passage.

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LC01274

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