House Bill #5634 (2017)

AN ACT RELATING TO INSURANCE ACCIDENT AND SICKNESS INSURANCE POLICIES

Permits 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.

View latest version | View original version
View status on official RI website

Subscribe to email updates


Changes since original draft

  • 2017 – H 5634
  • 2017 – H 5634 SUBSTITUTE B
  • ========
  • LC001663
  • LC001663/SUB B
  • ========
  • S T A T E O F R H O D E I S L A N D
  • S T A T E O F R H O D E I S L A N D
  • IN GENERAL ASSEMBLY
  • JANUARY SESSION, A.D. 2017
  • ____________
  • A N A C T
  • ____________
  • 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:
  • 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 known by the provider to be a pattern of inappropriate billing; 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.
  • (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 known by the provider to be a pattern of inappropriate billing; 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.
  • (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.
  • (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 known by the provider to be a pattern of inappropriate billing; 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.
  • (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 known by the provider to be a pattern of inappropriate billing; 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.
  • (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 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. This act shall take effect upon passage. ======== LC001663 ========
  • (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.
  • SECTION 6. This act shall take effect upon passage. ======== LC001663/SUB B ========
  • EXPLANATION
  • BY THE LEGISLATIVE COUNCIL
  • OF
  • A N A C T
  • RELATING TO INSURANCE ACCIDENT AND SICKNESS INSURANCE POLICIES
  • ***
  • 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. ======== LC001663 ========
  • This act would take effect upon passage. ======== LC001663/SUB B ========

Votes

NOTE: Electronic voting records are unofficial and may not be accurate. For an official vote tally, check the House or Senate Journal from the day of the vote.

Floor vote for PASSAGE

June 27, 2017 at 7:43pm
Yeas: 71 / Nays: 0 / Not voting: 4 / Recused: 0
Legislator Vote
Rep. Abney Y
Rep. Ackerman Y
Rep. Ajello Y
Rep. Almeida Y
Rep. Amore Y
Rep. Azzinaro Y
Rep. Barros Y
Rep. Bennett Y
Rep. Blazejewski Y
Rep. Canario Y
Rep. Carson Y
Rep. Casey Y
Rep. Casimiro Y
Rep. Chippendale Y
Rep. Corvese Y
Rep. Costantino NV
Rep. Coughlin Y
Rep. Craven Y
Rep. Cunha Y
Rep. Diaz NV
Rep. Donovan Y
Rep. Edwards Y
Rep. Fellela Y
Rep. Filippi Y
Rep. Fogarty Y
Rep. Giarrusso Y
Rep. Handy Y
Rep. Hearn Y
Rep. Hull Y
Rep. Jacquard Y
Rep. Johnston Y
Rep. Kazarian NV
Rep. Keable Y
Rep. Kennedy Y
Rep. Knight Y
Rep. Lancia Y
Rep. Lima Y
Rep. Lombardi Y
Rep. Maldonado Y
Rep. Marshall Y
Rep. Marszalkowski Y
Rep. Mattiello Y
Rep. McEntee Y
Rep. McKiernan Y
Rep. McLaughlin Y
Rep. McNamara Y
Rep. Mendonca Y
Rep. Messier Y
Rep. Morgan Y
Rep. Morin Y
Rep. Nardolillo Y
Rep. Newberry Y
Rep. Nunes Y
Rep. O'Brien Y
Rep. O'Grady Y
Rep. Perez Y
Rep. Phillips NV
Rep. Price Y
Rep. Quattrocchi Y
Rep. Ranglin-Vassell Y
Rep. Regunberg Y
Rep. Roberts Y
Rep. Ruggiero Y
Rep. Serpa Y
Rep. Shanley Y
Rep. Shekarchi Y
Rep. Slater Y
Rep. Solomon Y
Rep. Tanzi Y
Rep. Tobon Y
Rep. Ucci Y
Rep. Vella-Wilkinson Y
Rep. Walsh Y
Rep. Williams Y
Rep. Winfield Y

Floor vote for PASSAGE

September 19, 2017 at 8:32pm
Yeas: 61 / Nays: 0 / Not voting: 14 / Recused: 0
Legislator Vote
Rep. Abney Y
Rep. Ackerman Y
Rep. Ajello Y
Rep. Almeida Y
Rep. Amore NV
Rep. Azzinaro Y
Rep. Barros NV
Rep. Bennett Y
Rep. Blazejewski Y
Rep. Canario Y
Rep. Carson NV
Rep. Casey Y
Rep. Casimiro Y
Rep. Chippendale Y
Rep. Corvese Y
Rep. Costantino Y
Rep. Coughlin Y
Rep. Craven Y
Rep. Cunha Y
Rep. Diaz NV
Rep. Donovan Y
Rep. Edwards Y
Rep. Fellela Y
Rep. Filippi Y
Rep. Fogarty Y
Rep. Giarrusso Y
Rep. Handy Y
Rep. Hearn Y
Rep. Hull Y
Rep. Jacquard Y
Rep. Johnston Y
Rep. Kazarian Y
Rep. Keable Y
Rep. Kennedy NV
Rep. Knight Y
Rep. Lancia Y
Rep. Lima Y
Rep. Lombardi Y
Rep. Maldonado Y
Rep. Marshall Y
Rep. Marszalkowski Y
Rep. Mattiello Y
Rep. McEntee Y
Rep. McKiernan Y
Rep. McLaughlin Y
Rep. McNamara Y
Rep. Mendonca NV
Rep. Messier Y
Rep. Morgan NV
Rep. Morin Y
Rep. Nardolillo NV
Rep. Newberry Y
Rep. Nunes Y
Rep. O'Brien Y
Rep. O'Grady NV
Rep. Perez Y
Rep. Phillips Y
Rep. Price NV
Rep. Quattrocchi NV
Rep. Ranglin-Vassell NV
Rep. Regunberg NV
Rep. Roberts Y
Rep. Ruggiero Y
Rep. Serpa Y
Rep. Shanley Y
Rep. Shekarchi Y
Rep. Slater Y
Rep. Solomon Y
Rep. Tanzi Y
Rep. Tobon Y
Rep. Ucci Y
Rep. Vella-Wilkinson Y
Rep. Walsh NV
Rep. Williams Y
Rep. Winfield Y