Bill Text: MI HB4192 | 2013-2014 | 97th Legislature | Introduced

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Bill Title: Insurance; health; retrospective audits and reimbursement requests; limit health plan ability to request. Amends 1956 PA 218 (MCL 500.100 - 500.8302) by adding sec. 2006a. TIE BAR WITH: HB 4191'13

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced - Dead) 2013-02-07 - Printed Bill Filed 02/07/2013 [HB4192 Detail]

Download: Michigan-2013-HB4192-Introduced.html

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HOUSE BILL No. 4192

 

February 6, 2013, Introduced by Rep. Shirkey and referred to the Committee on Insurance.

 

     A bill to amend 1956 PA 218, entitled

 

"The insurance code of 1956,"

 

(MCL 500.100 to 500.8302) by adding section 2006a.

 

THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

 

     Sec. 2006a. (1) A health plan shall not retrospectively deny a

 

previously paid claim to a health professional or any part of a

 

previously paid claim to a health professional unless all of the

 

following are met:

 

     (a) The health plan has provided a written notice to the

 

health professional specifying the previously paid claim that is

 

being retrospectively denied and the reason for the retrospective

 

denial of that claim.

 

     (b) The time that has elapsed since the date of payment of the

 

previously paid claim does not exceed 12 months. A previously paid

 

claim may be retrospectively denied more than 12 months after the

 

date of payment, but only for 1 of the following reasons:

 

     (i) The claim was submitted fraudulently.

 

     (ii) The claim payment was incorrect because the health

 

professional or patient was already paid for the health care

 

services identified in the claim.

 

     (iii) The claim payment was for services covered by title XVIII,

 

title XIX, or title XXI.

 

     (iv) Subject to subsection (3), the claim payment is the

 

subject of adjustment with another health plan, administrator, or

 

payor under a coordination of benefits or other provision.

 

     (v) The claim payment is the subject of legal action.

 

     (2) A health plan shall not reduce other payments owed to a

 

health professional, withhold or set off against future payments to

 

a health professional, or reduce or affect future claim payments to

 

a health professional other than claim payments that are the

 

subject of the retrospective denial.

 

     (3) A health plan that retrospectively denies a previously

 

paid claim that is the subject of adjustment with another health

 

plan, administrator, or payor under a coordination of benefits

 

provision shall provide a written notice to the health professional

 

specifying the health plan, administrator, or payor that is

 

responsible for the payment of the claim and the address for

 

submission of the claim.

 

     (4) A health plan shall not retrospectively deny a previously

 

paid claim to a health professional or any part of a previously

 

paid claim to a health professional for any claim for which the

 

health plan verified the benefits or eligibility at the time the

 

service was provided by the health professional.

 

     (5) As used in this section:

 

     (a) "Health plan" means that term as defined in section 2006

 

and includes a nonprofit dental care corporation operating under

 

1963 PA 125, MCL 550.351 to 550.373.

 

     (b) "Health professional" means that term as defined in

 

section 2006.

 

     (c) "Retrospectively deny a previously paid claim" means an

 

attempt to retroactively collect payments already made to a health

 

professional with respect to a claim by requiring repayment of the

 

payments, reducing other payments currently owed to the health

 

professional, withholding or setting off against future payments,

 

or reducing or affecting the future claim payments to the health

 

professional in any other manner.

 

     (d) "Title XVIII" means the federal medicare program

 

established under title XVIII of the social security act, 42 USC

 

1395 to 1395kkk-1.

 

     (e) "Title XIX" means a program for medical assistance

 

established under title XIX of the social security act, 42 USC 1396

 

to 1396w-5.

 

     (f) "Title XXI" means state child health plans established

 

under title XXI of the social security act, 42 USC 1397aa to

 

1397mm.

 

     Enacting section 1. This amendatory act does not take effect

 

unless Senate Bill No. ____ or House Bill No. 4191(request no.

 

00273'13) of the 97th Legislature is enacted into law.