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.


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FISCAL NOTE ACT MAY APPLY

 

 

A BILL FOR

 

HB4820LRB100 17309 SMS 32470 b

1    AN ACT concerning regulation.
 
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
 
4    Section 5. The Illinois Insurance Code is amended by
5changing Section 368d as follows:
 
6    (215 ILCS 5/368d)
7    Sec. 368d. Recoupments.
8    (a) A health care professional or health care provider
9shall be provided a remittance advice, which must include an
10explanation of a recoupment or offset taken by an insurer,
11health maintenance organization, independent practice
12association, or physician hospital organization, if any. The
13recoupment explanation shall, at a minimum, include the name of
14the patient; the date of service; the service code or if no
15service code is available a service description; the recoupment
16amount; and the reason for the recoupment or offset. In
17addition, an insurer, health maintenance organization,
18independent practice association, or physician hospital
19organization shall provide with the remittance advice, or with
20any demand for recoupment or offset, a telephone number or
21mailing address to initiate an appeal of the recoupment or
22offset together with the deadline for initiating an appeal.
23Such information shall be prominently displayed on the

 

 

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1remittance advice or written document containing the demand for
2recoupment or offset. Any appeal of a recoupment or offset by a
3health care professional or health care provider must be made
4within 60 days after receipt of the remittance advice. In
5addition, remittance advice may not reject a Current Procedural
6Terminology code without clear explanation of the reason.
7Remittance advice must provide for payment for all services
8provided, including when more than one procedure is performed
9in one day.
10    (b) It is not a recoupment when a health care professional
11or health care provider is paid an amount prospectively or
12concurrently under a contract with an insurer, health
13maintenance organization, independent practice association, or
14physician hospital organization that requires a retrospective
15reconciliation based upon specific conditions outlined in the
16contract.
17    (c) No recoupment or offset may be requested or withheld
18from future payments 60 days 18 months or more after the
19original payment is made, except in cases in which:
20        (1) a court, government administrative agency, other
21    tribunal, or independent third-party arbitrator makes or
22    has made a formal finding of fraud or material
23    misrepresentation;
24        (2) an insurer is acting as a plan administrator for
25    the Comprehensive Health Insurance Plan under the
26    Comprehensive Health Insurance Plan Act; or

 

 

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1        (3) the provider has already been paid in full by any
2    other payer, third party, or workers' compensation
3    insurer.
4No contract between an insurer and a health care professional
5or health care provider may provide for recoupments in
6violation of this Section. Nothing in this Section shall be
7construed to preclude insurers, health maintenance
8organizations, independent practice associations, or physician
9hospital organizations from resolving coordination of benefits
10between or among each other, including, but not limited to,
11resolution of workers' compensation and third-party liability
12cases, without recouping payment from the provider beyond the
1360-day 18-month time limit provided in this subsection (c).
14(Source: P.A. 97-556, eff. 1-1-12.)
 
15    Section 10. The Illinois Public Aid Code is amended by
16adding Section 12-4.25d as follows:
 
17    (305 ILCS 5/12-4.25d new)
18    Sec. 12-4.25d. Recoupments. For payments made under this
19Code, the Department of Healthcare and Family Services may
20recover money improperly or erroneously paid, or overpayments,
21either by setoff, crediting against future billings, or by
22requiring direct repayment to the Department of Healthcare and
23Family Services only within 60 days of any payment.