The Massachusetts Medical
Society wishes to be recorded in support of the above-referenced bill that
would limit retroactive denials of claims by health insurers.
House Bill 2193 would bar
all health insurers – including Medicaid – from recovering payments made to
providers more than 12 months after the payment of the claim. The insurer would also have to give at least
15 days advance written notice of the intent to recover, giving the provider an
opportunity to request additional information needed to verify or contest the
validity of the denial. The 12 month
limitation would not apply to claims in which an insurer is alleging fraud,
double billing or the non-provision of services. The notification would also trigger a
six-month period allowing the provider to submit the challenged claim to
another insurer.
There is currently no
limitation on insurers’ ability to recoup payments already made, even in cases
where no fraud is alleged. The Medical
Society has been made aware of cases where such recoupments have been demanded three years after payment. It is difficult for physicians and other
health care providers to challenge these actions, since most records are placed
in “dead storage” soon after a year and are not easily accessible in a cost effective
manner. Thus, recoupment challenges are
often too costly to defend against and payments already received are
inappropriately lost.
The MMS has adopted policy
which recommends that: “Legislation for payment recoupment include provisions
stating: (1) Notification of errors in payment must be given to the provider
within three months of the initial payment; (2) if an insurer claim payment
recoupment is in error, the insurance company will pay interest to the
physician, plus the original claim payment amount, with the interest calculated
from the original date of claim submission; and (3) when notified of an
overpayment on a claim, the insurance company cannot perform automatic
recoupments. Physicians, when notified,
will have 35 days to contest the overpayment before payment is due.”
We urge the
Committee to report out House Bill 2193 favorably.
