BILL REQ. #:  S-3648.1 

Read first time 01/14/2004.   Referred to Committee on Health & Long-Term Care.

     AN ACT Relating to regulating insurance overpayment recovery practices; adding a new section to chapter 48.20 RCW; adding a new section to chapter 48.21 RCW; adding a new section to chapter 48.44 RCW; and adding a new section to chapter 48.46 RCW.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

NEW SECTION.  Sec. 1   A new section is added to chapter 48.20 RCW to read as follows:
     (1) As used in this section, "health care provider" has the same meaning as in RCW 48.43.005.
     (2) An insurer may not retroactively deny, adjust, or seek recoupment or refund of a paid claim for health care expenses submitted by a health care provider for any reason, other than fraud or coordination of benefits, after the expiration of one year from the date that the initial claim was paid. Retroactive denials, adjustments, recoupments, or refunds based on coordination of benefits are governed by subsection (3) of this section. Notwithstanding any other provision of law or contract to the contrary, if an insurer retroactively denies, adjusts, or seeks recoupment or refund of a paid claim, the health care provider has an additional period of six months from the date that the notice required by subsection (4) of this section was received within which to file either a revised claim or a request for reconsideration with additional medical records or information.
     (3) An insurer may not retroactively deny, adjust, or seek recoupment or refund of a paid claim submitted by a health care provider for reasons related to coordination of benefits with another insurer or entity responsible for payment of the claim after the expiration of eighteen months from the date that the original claim was paid. If the insurer retroactively denies, adjusts, or seeks recoupment or refund of a paid claim based on coordination of benefits, the insurer must provide the health care provider with notice specifying the reason for the denial, adjustment, recoupment, or refund, and provide the name and address of the entity acknowledging responsibility for payment of the denied claim. Notwithstanding any other provision of law or contract to the contrary, if an insurer retroactively denies reimbursement for services as a result of coordination of benefits with another insurer, the health care provider has an additional six months from the date that the health care provider received the notice specified in this subsection to submit a claim for reimbursement for the service to the insurer, health service corporation, health benefit plan, medical assistance program, government health benefit program, or other entity responsible for payment for the services provided.
     (4) An insurer that retroactively denies, adjusts, or seeks recoupment or refund of a paid claim submitted by a health care provider must give the health care provider notice specifying the reason for the action taken. Any retroactive denials, adjustments, or requests for recoupment or refund of previous payments that are based upon medical necessity determinations, level of service determinations, coding errors, or billing irregularities must be reconciled to specific claims. A health care provider who disputes or contests the basis for the retroactive denial, adjustment, or request for recoupment or refund on all or any portion of a claim must notify the insurer within thirty days after the provider receives the notice that the retroactive denial, adjustment, or request for recoupment or refund for overpayment is disputed or contested. If the health care provider disputes or contests the retroactive denial, adjustment, or request for recoupment or refund, then any disputed or contested overpayment is not subject to recoupment, refunds, or adjustment by the insurer until all the appeals procedures, hearings, or other remedies available to the health care provider have been finally decided in favor of the insurer.
     (5) The requirements of this section may not be waived between the health care provider and an insurer. This section does not prevent or preclude an insurer from recovering in a court of law from a subscriber, enrollee, or beneficiary any amounts paid to a health care provider for benefits to which the subscriber, enrollee, or beneficiary was not entitled under the terms and conditions of the contract of insurance or the coverage agreement if the insurer is barred from seeking a retroactive denial, adjustment, or request for recoupment or refund from the health care provider under this section.

NEW SECTION.  Sec. 2   A new section is added to chapter 48.21 RCW to read as follows:
     (1) As used in this section, "health care provider" has the same meaning as in RCW 48.43.005.
     (2) An insurer may not retroactively deny, adjust, or seek recoupment or refund of a paid claim for health care expenses submitted by a health care provider for any reason, other than fraud or coordination of benefits, after the expiration of one year from the date that the initial claim was paid. Retroactive denials, adjustments, recoupments, or refunds based on coordination of benefits are governed by subsection (3) of this section. Notwithstanding any other provision of law or contract to the contrary, if an insurer retroactively denies, adjusts, or seeks recoupment or refund of a paid claim, the health care provider has an additional period of six months from the date that the notice required by subsection (4) of this section was received within which to file either a revised claim or a request for reconsideration with additional medical records or information.
     (3) An insurer may not retroactively deny, adjust, or seek recoupment or refund of a paid claim submitted by a health care provider for reasons related to coordination of benefits with another insurer or entity responsible for payment of the claim after the expiration of eighteen months from the date that the original claim was paid. If the insurer retroactively denies, adjusts, or seeks recoupment or refund of a paid claim based on coordination of benefits, the insurer must provide the health care provider with notice specifying the reason for the denial, adjustment, recoupment, or refund, and provide the name and address of the entity acknowledging responsibility for payment of the denied claim. Notwithstanding any other provision of law or contract to the contrary, if an insurer retroactively denies reimbursement for services as a result of coordination of benefits with another insurer, the health care provider has an additional six months from the date that the health care provider received the notice specified in this subsection to submit a claim for reimbursement for the service to the insurer, health service corporation, health benefit plan, medical assistance program, government health benefit program, or other entity responsible for payment for the services provided.
     (4) An insurer that retroactively denies, adjusts, or seeks recoupment or refund of a paid claim submitted by a health care provider must give the health care provider notice specifying the reason for the action taken. Any retroactive denials, adjustments, or requests for recoupment or refund of previous payments that are based upon medical necessity determinations, level of service determinations, coding errors, or billing irregularities must be reconciled to specific claims. A health care provider who disputes or contests the basis for the retroactive denial, adjustment, or request for recoupment or refund on all or any portion of a claim must notify the insurer within thirty days after the provider receives the notice that the retroactive denial, adjustment, or request for recoupment or refund for overpayment is disputed or contested. If the health care provider disputes or contests the retroactive denial, adjustment, or request for recoupment or refund, then any disputed or contested overpayment is not subject to recoupment, refunds, or adjustment by the insurer until all the appeals procedures, hearings, or other remedies available to the health care provider have been finally decided in favor of the insurer.
     (5) The requirements of this section may not be waived between the health care provider and an insurer. This section does not prevent or preclude an insurer from recovering in a court of law from a subscriber, enrollee, or beneficiary any amounts paid to a health care provider for benefits to which the subscriber, enrollee, or beneficiary was not entitled under the terms and conditions of the contract of insurance or the coverage agreement if the insurer is barred from seeking a retroactive denial, adjustment, or request for recoupment or refund from the health care provider under this section.

NEW SECTION.  Sec. 3   A new section is added to chapter 48.44 RCW to read as follows:
     (1) As used in this section, "health care provider" has the same meaning as in RCW 48.43.005.
     (2) A health care service contractor may not retroactively deny, adjust, or seek recoupment or refund of a paid claim for health care expenses submitted by a health care provider for any reason, other than fraud or coordination of benefits, after the expiration of one year from the date that the initial claim was paid. Retroactive denials, adjustments, recoupments, or refunds based on coordination of benefits are governed by subsection (3) of this section. Notwithstanding any other provision of law or contract to the contrary, if a health care service contractor retroactively denies, adjusts, or seeks recoupment or refund of a paid claim, the health care provider has an additional period of six months from the date that the notice required by subsection (4) of this section was received within which to file either a revised claim or a request for reconsideration with additional medical records or information.
     (3) A health care service contractor may not retroactively deny, adjust, or seek recoupment or refund of a paid claim submitted by a health care provider for reasons related to coordination of benefits with another insurer or entity responsible for payment of the claim after the expiration of eighteen months from the date that the original claim was paid. If the health care service contractor retroactively denies, adjusts, or seeks recoupment or refund of a paid claim based on coordination of benefits, the health care service contractor must provide the health care provider with notice specifying the reason for the denial, adjustment, recoupment, or refund, and provide the name and address of the entity acknowledging responsibility for payment of the denied claim. Notwithstanding any other provision of law or contract to the contrary, if a health care service contractor retroactively denies reimbursement for services as a result of coordination of benefits with another insurer, the health care provider has an additional six months from the date that the health care provider received the notice specified in this subsection to submit a claim for reimbursement for the service to the insurer, health service corporation, health benefit plan, medical assistance program, government health benefit program, or other entity responsible for payment for the services provided.
     (4) A health care service contractor that retroactively denies, adjusts, or seeks recoupment or refund of a paid claim submitted by a health care provider must give the health care provider notice specifying the reason for the action taken. Any retroactive denials, adjustments, or requests for recoupment or refund of previous payments that are based upon medical necessity determinations, level of service determinations, coding errors, or billing irregularities must be reconciled to specific claims. A health care provider who disputes or contests the basis for the retroactive denial, adjustment, or request for recoupment or refund on all or any portion of a claim must notify the health care service contractor within thirty days after the provider receives the notice that the retroactive denial, adjustment, or request for recoupment or refund for overpayment is disputed or contested. If the health care provider disputes or contests the retroactive denial, adjustment, or request for recoupment or refund, then any disputed or contested overpayment is not subject to recoupment, refunds, or adjustment by the health care service contractor until all the appeals procedures, hearings, or other remedies available to the health care provider have been finally decided in favor of the health care service contractor.
     (5) The requirements of this section may not be waived between the health care provider and a health care service contractor. This section does not prevent or preclude a health care service contractor from recovering in a court of law from a subscriber, enrollee, or beneficiary any amounts paid to a health care provider for benefits to which the subscriber, enrollee, or beneficiary was not entitled under the terms and conditions of the contract of insurance or the coverage agreement if the health care service contractor is barred from seeking a retroactive denial, adjustment, or request for recoupment or refund from the health care provider under this section.

NEW SECTION.  Sec. 4   A new section is added to chapter 48.46 RCW to read as follows:
     (1) As used in this section, "health care provider" has the same meaning as in RCW 48.43.005.
     (2) A health maintenance organization may not retroactively deny, adjust, or seek recoupment or refund of a paid claim for health care expenses submitted by a health care provider for any reason, other than fraud or coordination of benefits, after the expiration of one year from the date that the initial claim was paid. Retroactive denials, adjustments, recoupments, or refunds based on coordination of benefits are governed by subsection (3) of this section. Notwithstanding any other provision of law or contract to the contrary, if a health maintenance organization retroactively denies, adjusts, or seeks recoupment or refund of a paid claim, the health care provider has an additional period of six months from the date that the notice required by subsection (4) of this section was received within which to file either a revised claim or a request for reconsideration with additional medical records or information.
     (3) A health maintenance organization may not retroactively deny, adjust, or seek recoupment or refund of a paid claim submitted by a health care provider for reasons related to coordination of benefits with another insurer or entity responsible for payment of the claim after the expiration of eighteen months from the date that the original claim was paid. If the health maintenance organization retroactively denies, adjusts, or seeks recoupment or refund of a paid claim based on coordination of benefits, the health maintenance organization must provide the health care provider with notice specifying the reason for the denial, adjustment, recoupment, or refund, and provide the name and address of the entity acknowledging responsibility for payment of the denied claim. Notwithstanding any other provision of law or contract to the contrary, if a health maintenance organization retroactively denies reimbursement for services as a result of coordination of benefits with another insurer, the health care provider has an additional six months from the date that the health care provider received the notice specified in this subsection to submit a claim for reimbursement for the service to the insurer, health service corporation, health benefit plan, medical assistance program, government health benefit program, or other entity responsible for payment for the services provided.
     (4) A health maintenance organization that retroactively denies, adjusts, or seeks recoupment or refund of a paid claim submitted by a health care provider must give the health care provider notice specifying the reason for the action taken. Any retroactive denials, adjustments, or requests for recoupment or refund of previous payments that are based upon medical necessity determinations, level of service determinations, coding errors, or billing irregularities must be reconciled to specific claims. A health care provider who disputes or contests the basis for the retroactive denial, adjustment, or request for recoupment or refund on all or any portion of a claim must notify the health maintenance organization within thirty days after the provider receives the notice that the retroactive denial, adjustment, or request for recoupment or refund for overpayment is disputed or contested. If the health care provider disputes or contests the retroactive denial, adjustment, or request for recoupment or refund, then any disputed or contested overpayment is not subject to recoupment, refunds, or adjustment by the health maintenance organization until all the appeals procedures, hearings, or other remedies available to the health care provider have been finally decided in favor of the health maintenance organization.
     (5) The requirements of this section may not be waived between the health care provider and a health maintenance organization. This section does not prevent or preclude a health maintenance organization from recovering in a court of law from a subscriber, enrollee, or beneficiary any amounts paid to a health care provider for benefits to which the subscriber, enrollee, or beneficiary was not entitled under the terms and conditions of the contract of insurance or the coverage agreement if the health maintenance organization is barred from seeking a retroactive denial, adjustment, or request for recoupment or refund from the health care provider under this section.