H1000B1171A00824       JLW:CMM 05/24/07    #90             A00824
                       AMENDMENTS TO HOUSE BILL NO. 1000
                                    Sponsor:  REPRESENTATIVE BARRAR
                                           Printer's No. 1171

     1       Amend Title, page 1, line 11, by striking out "providing,"
     2    and inserting
     3               providing for retroactive denial of reimbursement of
     4               payments to health care providers by insurers and,

     5       Amend Bill, page 2, lines 2 through 4, by striking out all of
     6    said lines and inserting
     7       Section 1.  The act of May 17, 1921 (P.L.682, No.284), known
     8    as The Insurance Company Law of 1921, is amended by adding an
     9    article to read:
    10                              ARTICLE VI-B
    12    § 601-B.  Scope of article.
    13       This article shall not apply to reimbursements made as part
    14    of an annual contracted reconciliation of a risk-sharing
    15    arrangement under an administrative service provider contract.
    16    § 602-B.  Definitions.
    17       The following words and phrases when used in this article
    18    shall have the meanings given to them in this section unless the
    19    context clearly indicates otherwise:
    20       "Code."  Any of the following codes:
    21           (1)  The applicable Current Procedural Terminology (CPT)
    22       code, as adopted by the American Medical Association.
    23           (2)  If for dental service, the applicable code adopted
    24       by the American Dental Association.
    25           (3)  Another applicable code under an appropriate uniform
    26       coding scheme used by an insurer in accordance with this
    27       article.
    28       "Coding guidelines."  Those standards or procedures used or
    29    applied by a payor to determine the most accurate and
    30    appropriate code or codes for payment by the payor for a service
    31    or services.
    32       "Fraud."  The intentional misrepresentation or concealment of
    33    information in order to deceive or mislead.
    34       "Health care provider."  A person, corporation, facility,
    35    institution or other entity licensed, certified or approved by
    36    the Commonwealth to provide health care or professional medical
    37    services. The term includes, but is not limited to, a physician,
    38    chiropractor, optometrist, professional nurse, certified nurse-
    39    midwife, podiatrist, hospital, nursing home, ambulatory surgical

     1    center or birth center.
     2       "Insurer."  An entity subject to any of the following:
     3           (1)  40 Pa.C.S. Ch. 61 (relating to hospital plan
     4       corporations) or 63 (relating to professional health services
     5       plan corporations).
     6           (2)  This act.
     7           (3)  The act of December 29, 1972 (P.L.1701, No.364),
     8       known as the Health Maintenance Organization Act.
     9       "Medical assistance program."  The program established under
    10    the act of June 13, 1967 (P.L.31, No.21), known as the Public
    11    Welfare Code.
    12       "Medicare."  The Federal program established under Title
    13    XVIII of the Social Security Act (49 Stat. 620, 42 U.S.C. § 301
    14    et seq. or 1395 et seq.).
    15       "Reimbursement."  Payments made to a health care provider by
    16    an insurer on either a fee-for-service, capitated or premium
    17    basis.
    18    § 603-B.  Retroactive denial of reimbursement.
    19       (a)  General rule.--If an insurer retroactively denies
    20    reimbursement to a health care provider, the insurer may only:
    21           (1)  retroactively deny reimbursement for services
    22       subject to coordination of benefits with another insurer, the
    23       medical assistance program or the Medicare program during the
    24       12-month period after the date that the insurer paid the
    25       health care provider; and
    26           (2)  except as provided in paragraph (1), retroactively
    27       deny reimbursement during a 12-month period after the date
    28       that the insurer paid the health care provider.
    29       (b)  Written notice.--An insurer that retroactively denies
    30    reimbursement to a health care provider under subsection (a)
    31    shall provide the health care provider with a written statement
    32    specifying the basis for the retroactive denial. If the
    33    retroactive denial of reimbursement results from coordination of
    34    benefits, the written statement shall provide the name and
    35    address of the entity acknowledging responsibility for payment
    36    of the denied claim.
    37    § 604-B.  Effect of noncompliance.
    38       Except as provided in section 605-B, an insurer that does not
    39    comply with the provisions of section 603-B may not
    40    retroactively deny reimbursement or attempt in any manner to
    41    retroactively collect reimbursement already paid to a health
    42    care provider.
    43    § 605-B.  Fraudulent or improperly coded information.
    44       (a)  Reasons for denial.--The provisions of section 603-B do
    45    not apply if an insurer retroactively denies reimbursement to a
    46    health care provider because:
    47           (1)  the information submitted to the insurer was
    48       fraudulent;
    49           (2)  the information submitted to the insurer was
    50       improperly coded and the insurer has provided to the health
    51       care provider sufficient information regarding the coding
    52       guidelines used by the insurer at least 30 days prior to the
    53       date the services subject to the retroactive denial were
    54       rendered; or
    55           (3)  the claim submitted to the insurer was a duplicate
    56       claim.
    57       (b)  Improper coding.--Information submitted to the insurer
    58    may be considered to be improperly coded under subsection (a)(2)
    59    if the information submitted to the insurer by the health care

    HB1000A00824                     - 2 -     

     1    provider:
     2           (1)  uses codes that do not conform with the coding
     3       guidelines used by the carrier applicable as of the date the
     4       service or services were rendered; or
     5           (2)  does not otherwise conform with the contractual
     6       obligations of the health care provider to the insurer
     7       applicable as of the date the service or services were
     8       rendered.
     9    § 606-B.  Coordination of benefits.
    10       If an insurer retroactively denies reimbursement for services
    11    as a result of coordination of benefits under provisions of
    12    section 605-B(a), the health care provider shall have six months
    13    from the date of the denial, unless an insurer permits a longer
    14    time period, to submit a claim for reimbursement for the service
    15    to the insurer, the medical assistance program or Medicare
    16    program responsible for payment.
    17       Section 2.  The act is amended by adding a section to read:

    18       Amend Sec. 2, page 2, line 15, by striking out "2" and
    19    inserting
    20               3
    21       Amend Sec. 3, page 2, line 27, by striking out "3" and
    22    inserting
    23               4

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