BILL REQ. #:  H-2457.1 

READ FIRST TIME 03/08/05.   

     AN ACT Relating to regulating insurance overpayment recovery practices; adding a new section to chapter 48.43 RCW; and providing an effective date.

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

NEW SECTION.  Sec. 1   A new section is added to chapter 48.43 RCW to read as follows:
     (1) A carrier may not retroactively deny, adjust, or seek recoupment or refund of a paid claim submitted by a health care provider for any reason, other than fraud or coordination of benefits or as set forth in subsection (5) of this section, after the expiration of one year from the date the initial claim was paid. If a carrier 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 the notice required by subsection (6) of this section was received within which to file either a revised claim or a request for reconsideration supported by additional medical records or information.
     (2) A health care provider may not retroactively seek adjustment of a claim payment by a carrier for any reason, other than fraud or coordination of benefits, after the expiration of one year from the date the initial claim was paid. If a provider retroactively seeks an adjustment of a paid claim, the carrier has an additional period of six months from the date the notice required by subsection (6) of this section was received within which to file a response.
     (3) A carrier 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 carrier or other entity responsible for payment of the claim after the expiration of eighteen months from the date the original claim was paid by the primary or secondary payer, regardless who is seeking the adjustment or recoupment. A carrier may not unreasonably delay initial payment of a claim to a health care provider because of carrier efforts to coordinate benefits nor may a carrier require the provider to assume responsibility for coordination of benefits except to provide the carrier information. If the carrier retroactively denies, adjusts, or seeks recoupment or refund of a paid claim based on coordination of benefits, the carrier 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 that has acknowledged responsibility for payment of the denied claim. The health care provider has an additional six months from the date the health care provider received the notice specified in this subsection to submit a claim for reimbursement for the health care service to the carrier, medical assistance program, government health benefit program, or any other entity responsible for payment of services provided.
     (4) A health care provider may not retroactively seek adjustment of a claim payment by a carrier for reasons related to coordination of benefits with another carrier or other entity responsible for payment of the claim after the expiration of eighteen months from the date the original claim was paid. If a provider retroactively seeks adjustment of a paid claim based on coordination of benefits, the health care provider must provide the carrier with notice specifying the reason for the adjustment, and provide the name and address of the entity that has failed to acknowledge responsibility for payment of the claim. The carrier has an additional six months from the date the carrier receives the notice specified in this subsection to respond.
     (5) To prevent duplicate recovery for the same health service, a carrier may seek recoupment, adjustment, or refund of a claim paid to a health care provider after the expiration of one year from the date the initial claim was paid if: (a) The carrier is seeking recovery of a claim payment owed by a third party, including government entities, as a consequence of liability imposed by law, such as that arising from tort liability; and (b) the carrier is unable to seek recovery directly from the third party because the third party either has paid or will pay the provider for the same health service as the initial claim.
     (6) A carrier or health care provider that retroactively denies, adjusts, or seeks recoupment, adjustment, or refund of a paid claim must give the other party written notice specifying the reason for the action taken. Any actions that are based upon medical necessity determinations, level of service determinations, coding errors, or billing irregularities must be reconciled by the carrier or the provider to the specific claims in question.
     (7) A health care provider or a carrier has thirty days after receipt of the notice under subsection (6) of this section in which to notify the other party that they are disputing or contesting the action. When a provider or a carrier fails to respond in writing in thirty days to a written notice of recoupment or adjustment, the carrier or provider may consider the recoupment or adjustment accepted. If the health care provider or a carrier disputes or contests the action, then any disputed or contested claim payment is not subject to recoupment, refunds, or adjustment by the other party until all the appeals procedures, hearings, or other remedies available to the health care provider and the carrier have been finally decided. If the decision is favorable to the carrier, any disputed payment may be offset in a future claim payment for that provider.
     (8) The requirements of this section may not be waived by contract or otherwise by the health care provider or carrier. This section neither permits nor precludes a carrier from recovering 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 health plan, insurance policy, or other benefit agreement.
     (9) This section does not apply to carrier or provider payment or recoupment practices with respect to claims or payments for health care services under health plans providing only dental coverage, health care services provided under Title XVIII (medicare) of the social security act, or medicare supplemental plans regulated under chapter 48.66 RCW.

NEW SECTION.  Sec. 2   This act takes effect January 1, 2006.