Bill Text: IL HB4820 | 2017-2018 | 100th General Assembly | Introduced

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Bill Title: Amends the Accident and Health Insurance Article of the Illinois Insurance Code. Provides that remittance advice for recoupment may not reject a Current Procedural Terminology code without clear explanation of the reasons. Requires remittance advice to provide for payment for all services provided, including when more than one procedure is performed in one day. Requires that a recoupment or offset be requested or withheld from future payments within 60 days (rather than 18 months) of the original payment, unless one of the specific exceptions applies. Amends the Illinois Public Aid Code. Allows the Department of Healthcare and Family Services to recover money improperly or erroneously paid, or overpayments, within 60 days of any payment.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Failed) 2019-01-08 - Session Sine Die [HB4820 Detail]

Download: Illinois-2017-HB4820-Introduced.html

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100TH GENERAL ASSEMBLY State of Illinois 2017 and 2018 HB4820 Introduced , by Rep. Laura Fine SYNOPSIS AS INTRODUCED:
215 ILCS 5/368d
305 ILCS 5/12-4.25d new
Amends the Accident and Health Insurance Article of the Illinois Insurance Code. Provides that remittance advice for recoupment may not reject a Current Procedural Terminology code without clear explanation of the reasons. Requires remittance advice to provide for payment for all services provided, including when more than one procedure is performed in one day. Requires that a recoupment or offset be requested or withheld from future payments within 60 days (rather than 18 months) of the original payment, unless one of the specific exceptions applies. Amends the Illinois Public Aid Code. Allows the Department of Healthcare and Family Services to recover money improperly or erroneously paid, or overpayments, within 60 days of any payment.
LRB100 17309 SMS 32470 b
FISCAL NOTE ACT MAY APPLY
A BILL FOR
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AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Insurance Code is amended by
changing Section 368d as follows:
(215 ILCS 5/368d)
Sec. 368d. Recoupments.
(a) A health care professional or health care provider
shall be provided a remittance advice, which must include an
explanation of a recoupment or offset taken by an insurer,
health maintenance organization, independent practice
association, or physician hospital organization, if any. The
recoupment explanation shall, at a minimum, include the name of
the patient; the date of service; the service code or if no
service code is available a service description; the recoupment
amount; and the reason for the recoupment or offset. In
addition, an insurer, health maintenance organization,
independent practice association, or physician hospital
organization shall provide with the remittance advice, or with
any demand for recoupment or offset, a telephone number or
mailing address to initiate an appeal of the recoupment or
offset together with the deadline for initiating an appeal.
Such information shall be prominently displayed on the

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remittance advice or written document containing the demand for
recoupment or offset. Any appeal of a recoupment or offset by a
health care professional or health care provider must be made
within 60 days after receipt of the remittance advice. In
addition, remittance advice may not reject a Current Procedural
Terminology code without clear explanation of the reason.
Remittance advice must provide for payment for all services
provided, including when more than one procedure is performed
in one day.
(b) It is not a recoupment when a health care professional
or health care provider is paid an amount prospectively or
concurrently under a contract with an insurer, health
maintenance organization, independent practice association, or
physician hospital organization that requires a retrospective
reconciliation based upon specific conditions outlined in the
contract.
(c) No recoupment or offset may be requested or withheld
from future payments 60 days 18 months or more after the
original payment is made, except in cases in which:
(1) a court, government administrative agency, other
tribunal, or independent third-party arbitrator makes or
has made a formal finding of fraud or material
misrepresentation;
(2) an insurer is acting as a plan administrator for
the Comprehensive Health Insurance Plan under the
Comprehensive Health Insurance Plan Act; or

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(3) the provider has already been paid in full by any
other payer, third party, or workers' compensation
insurer.
No contract between an insurer and a health care professional
or health care provider may provide for recoupments in
violation of this Section. Nothing in this Section shall be
construed to preclude insurers, health maintenance
organizations, independent practice associations, or physician
hospital organizations from resolving coordination of benefits
between or among each other, including, but not limited to,
resolution of workers' compensation and third-party liability
cases, without recouping payment from the provider beyond the
60-day 18-month time limit provided in this subsection (c).
(Source: P.A. 97-556, eff. 1-1-12.)
Section 10. The Illinois Public Aid Code is amended by
adding Section 12-4.25d as follows:
(305 ILCS 5/12-4.25d new)
Sec. 12-4.25d. Recoupments. For payments made under this
Code, the Department of Healthcare and Family Services may
recover money improperly or erroneously paid, or overpayments,
either by setoff, crediting against future billings, or by
requiring direct repayment to the Department of Healthcare and
Family Services only within 60 days of any payment.