2013 -- S 0536 SUBSTITUTE A

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LC01274/SUB A

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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) Except as otherwise provided herein, any review,

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

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

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to such claims shall be completed no later than two (2) years eighteen (18) months after the

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completed claims were initially paid. This section shall not restrict any review, audit or

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investigation regarding claims that are submitted fraudulently, are subject to a pattern of

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inappropriate billing, are related to coordination of benefits, are duplicate claims, or are subject to

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any federal law or regulation that permits claims review 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 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.

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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 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) Except as otherwise provided herein, any review,

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audit or investigation by a nonprofit hospital service corporation 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 eighteen (18) months after

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the completed claims were initially paid. This section shall not restrict any review, audit or

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investigation regarding claims that are submitted fraudulently, are subject to a pattern of

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inappropriate billing, are related to coordination of benefits, are duplicate claims, or are subject to

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any federal law or regulation that permits claims review 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 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.

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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 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) Except as otherwise provided herein, any review,

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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 eighteen

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(18) months after the completed claims were initially paid. This section shall not restrict any

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review, audit or investigation regarding claims that are submitted fraudulently, are subject to a

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pattern of inappropriate billing, are related to coordination of benefits, are duplicate claims, or are

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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

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a 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.

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

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audit or investigation by a health maintenance organization 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 eighteen (18) months after

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the completed claims were initially paid. This section shall not restrict any review, audit or

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investigation regarding claims that are submitted fraudulently, are subject to a pattern of

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inappropriate billing, are related to coordination of benefits, are duplicate claims, or are subject to

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any federal law or regulation that permits claims review 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 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.

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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. This act shall take effect on January 1, 2014.

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LC01274/SUB A

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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 eighteen (18) months and would establish an appeals process

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prior to any recoupment or set-off. It would also allow the parties to health insurance plans to

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negotiate different time frames than specified herein.

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     This act would take effect on January 1, 2014.

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LC01274/SUB A

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