101ST GENERAL ASSEMBLY
State of Illinois
2019 and 2020
SB2771

 

Introduced 2/4/2020, by Sen. Laura Fine

 

SYNOPSIS AS INTRODUCED:
 
215 ILCS 5/368d

    Amends the Illinois Insurance Code. Provides that an insurer, health maintenance organization, independent practice association, or physician hospital organization may not attempt a recoupment or offset until all appeal rights of a health care professional or health care provider are exhausted. Provides that no recoupment or offset may be requested or withheld from future payments 6 months or more after the original payment is made (rather than 18 months or more after the original payment is made). Effective January 1, 2021.


LRB101 16652 BMS 66039 b

 

 

A BILL FOR

 

SB2771LRB101 16652 BMS 66039 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. An
5insurer, health maintenance organization, independent practice
6association, or physician hospital organization may not
7attempt a recoupment or offset until all appeal rights are
8exhausted.
9    (b) It is not a recoupment when a health care professional
10or health care provider is paid an amount prospectively or
11concurrently under a contract with an insurer, health
12maintenance organization, independent practice association, or
13physician hospital organization that requires a retrospective
14reconciliation based upon specific conditions outlined in the
15contract.
16    (c) No recoupment or offset may be requested or withheld
17from future payments 6 18 months or more after the original
18payment is made, except in cases in which:
19        (1) a court, government administrative agency, other
20    tribunal, or independent third-party arbitrator makes or
21    has made a formal finding of fraud or material
22    misrepresentation;
23        (2) an insurer is acting as a plan administrator for
24    the Comprehensive Health Insurance Plan under the
25    Comprehensive Health Insurance Plan Act; or
26        (3) the provider has already been paid in full by any

 

 

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1    other payer, third party, or workers' compensation
2    insurer.
3No contract between an insurer and a health care professional
4or health care provider may provide for recoupments in
5violation of this Section. Nothing in this Section shall be
6construed to preclude insurers, health maintenance
7organizations, independent practice associations, or physician
8hospital organizations from resolving coordination of benefits
9between or among each other, including, but not limited to,
10resolution of workers' compensation and third-party liability
11cases, without recouping payment from the provider beyond the
1218-month time limit provided in this subsection (c).
13(Source: P.A. 97-556, eff. 1-1-12.)
 
14    Section 99. Effective date. This Act takes effect January
151, 2021.