Bill Text: MS SB2988 | 2010 | Regular Session | Introduced
Bill Title: Health insurance; limit insurers' recoupment of payments to health care providers.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Failed) 2010-02-02 - Died In Committee [SB2988 Detail]
Download: Mississippi-2010-SB2988-Introduced.html
MISSISSIPPI LEGISLATURE
2010 Regular Session
To: Insurance
By: Senator(s) Gordon
Senate Bill 2988
AN ACT TO PROVIDE THAT, EXCEPT IN CASES OF FRAUD, A HEALTH CARE INSURER MAY EXERCISE RECOUPMENT FROM A HEALTH CARE PROVIDER ONLY DURING THE EIGHTEEN-MONTH PERIOD AFTER THE DATE THAT THE HEALTH CARE INSURER PAID THE CLAIM SUBMITTED BY THE PROVIDER; TO PROVIDE THAT A HEALTH CARE INSURER THAT EXERCISES RECOUPMENT UNDER THIS ACT SHALL GIVE THE HEALTH CARE PROVIDER A WRITTEN OR ELECTRONIC STATEMENT SPECIFYING THE BASIS FOR THE RECOUPMENT; TO PROVIDE THAT THE FAILURE TO COMPLY WITH ANY PROVISION OF THIS ACT SHALL BE DEEMED AN UNFAIR TRADE PRACTICE AND MAY BE PUNISHED BY CERTAIN FINES AND PENALTIES; TO REQUIRE THE COMMISSIONER OF INSURANCE TO ADOPT RULES AND REGULATIONS TO ENSURE COMPLIANCE WITH THIS ACT; AND FOR RELATED PURPOSES.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MISSISSIPPI:
SECTION 1. Definitions. As used in this act:
(a) "Covered person" means a person on whose behalf a health care insurer offering health insurance coverage is obligated to pay benefits or provide services.
(b) "Health care insurer" means an entity subject to the insurance laws of this state or the jurisdiction of the Commissioner of Insurance that contracts or offers to contract to provide health insurance coverage, including, but not limited to, an insurance company, a health maintenance organization or a hospital medical service corporation.
(c) "Health care provider" means any person or entity providing:
(i) Medical, pharmaceutical, optometric or dental care;
(ii) Hospitalization; or
(iii) Any other services and goods used for the purpose or incidental to the purpose of preventing, alleviating, curing or healing human illness or injury.
(d) (i) "Health insurance coverage" means benefits consisting of medical, pharmaceutical, optometric or dental care, hospitalization, or other goods or services, for the purpose of preventing, alleviating, curing or healing human illness, provided, directly or indirectly, through insurance, reimbursement or otherwise, including items and services paid for under any policy, certificate or agreement offered by a health care insurer.
(ii) "Health insurance coverage" does not include policies or certificates covering only accident, credit, disability income, long-term care, hospital indemnity, Medicare
supplemental policy as defined in 42 USC Section 1395ss(g)(1), a specified disease, other limited benefit health insurance, automobile medical payment insurance, or claims under the Workers' Compensation Law, Section 71-3-1 et seq., or the Mississippi Comprehensive Health Insurance Risk Pool Association Act, Section 83-9-201 et seq.
(e) "Recoupment" means any action or attempt by a health care insurer to recover or collect payments already made to a health care provider with respect to a claim:
(i) By reducing other payments currently owed to the health care provider;
(ii) By withholding or setting off the amount against current or future payments to the health care provider;
(iii) By demanding payment back from a health care provider for a claim already paid; or
(iv) By any other manner that reduces or affects the future claim payments to the health care provider.
SECTION 2. Time for recoupment. (1) Except in cases of fraud committed by the health care provider, a health care insurer may exercise recoupment from a health care provider only during the eighteen-month period after the date that the health care insurer paid the claim submitted by the health care provider.
(2) (a) A health care insurer that exercises recoupment under this section shall give the health care provider a written or electronic statement specifying the basis for the recoupment.
(b) At a minimum, the statement shall contain the information required by Section 4 of this act.
SECTION 3. Persons not covered. (1) If a health care insurer determines that payment was made for services not covered under the covered person's health insurance coverage, the health care insurer shall give written notice to the health care provider of its intent to exercise recoupment and may:
(a) Request a refund from the health care provider; or
(b) Make a recoupment of the payment from the health care provider in accordance with Section 4 of this act.
(2) (a) Except in the case of fraud committed by the health care provider or as provided in subsection (2)(b) of this section, subsection (1) of this section shall not apply if a health care provider or other party on its behalf verified from the health care insurer or its agent that an individual was a covered person and if the health care provider in good faith provided services to the individual in reliance on the verification.
(b) A health care insurer has one hundred twenty (120) days from the date of payment to notify the provider of a verification error and the fact that services rendered will not be covered if the error was made in good faith at the time of the verification.
SECTION 4. Recoupments - required disclosures. If a health care insurer exercises recoupment, then the health care insurer shall provide the health care provider written documentation that specifies the:
(a) Amount of the recoupment;
(b) Covered person's name to whom the recoupment applies;
(c) Patient identification number;
(d) Date or dates of service;
(e) Service or services on which the recoupment is based;
(f) Pending claims being recouped or future claims that will be recouped; and
(g) Specific reason for the recoupment.
SECTION 5. Penalties. The failure to comply with any provision of this act shall be deemed an unfair trade practice under Sections 83-5-29 through 83-5-51, and may be punished by the fines and penalties established under Sections 83-5-29 through 83-5-51.
SECTION 6. Rules and regulations. The Commissioner of Insurance shall adopt rules and regulations to ensure compliance with this act.
SECTION 7. No waiver of provisions. The provisions of this act shall not be waived, voided or nullified by contract.
SECTION 8. This act shall take effect and be in force from and after July 1, 2010.
