102ND GENERAL ASSEMBLY
State of Illinois
2021 and 2022
SB1974

 

Introduced 2/26/2021, 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, 2022.


LRB102 12035 BMS 17371 b

 

 

A BILL FOR

 

SB1974LRB102 12035 BMS 17371 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
14of the patient; the date of service; the service code or if no
15service code is available a service description; the
16recoupment amount; and the reason for the recoupment or
17offset. In addition, an insurer, health maintenance
18organization, independent practice association, or physician
19hospital organization shall provide with the remittance
20advice, or with any demand for recoupment or offset, a
21telephone number or mailing address to initiate an appeal of
22the recoupment or offset together with the deadline for
23initiating an appeal. Such information shall be prominently

 

 

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1displayed on the remittance advice or written document
2containing the demand for recoupment or offset. Any appeal of
3a recoupment or offset by a health care professional or health
4care provider must be made within 60 days after receipt of the
5remittance advice. An insurer, health maintenance
6organization, independent practice association, or physician
7hospital organization may not attempt a recoupment or offset
8until all appeal rights are exhausted.
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, 2022.