SB 162

(136th General Assembly)
  (Amended Substitute Senate Bill Number 162)
  AN ACT
       To amend section 3901.388 of the Revised Code regarding the timeframe for health
  insurer recoupment from health care providers.
Be it enacted by the General Assembly of the State of Ohio:
        SECTION 1. That section 3901.388 of the Revised Code be amended to read as follows:
        Sec. 3901.388. (A) A payment made by a third-party payer to a provider in accordance with
sections 3901.381 to 3901.386 of the Revised Code shall be considered final two yearsone year after
payment is made. After that date, the amount of the payment is not subject to adjustment, except in
the case of fraud by the provider.
        (B) A third-party payer may recover the amount of any part of a payment that the third-party
payer determines to be an overpayment if the recovery process is initiated not later than two years
one year after the payment was made to the provider. The third-party payer shall inform the provider
of its determination of overpayment by providing notice in accordance with division (C) of this
section. The third-party payer shall give the provider an opportunity to appeal the determination and
shall not charge the provider a fee for an appeal. If the provider fails to respond to the notice sooner
than thirty within sixty days after the notice is made, elects not to appeal the determination, or
appeals the determination but the appeal is not uphelddenied, the third-party payer may initiate
recovery of the overpayment.
        When a provider has failed to make a timely response to the notice of the third-party payer's
determination of overpayment, the third-party payer may recover the overpayment by deducting the
amount of the overpayment from other payments the third-party payer owes the provider or by
taking action pursuant to any other remedy available under the Revised Code. When a provider
elects not to appeal a determination of overpayment or appeals the determination but the appeal is
not uphelddenied, the third-party payer shall permit a provider to repay the amount by making one
or more direct payments to the third-party payer or by having the amount deducted from other
payments the third-party payer owes the provider.
        (C)(C)(1) The notice of overpayment a third-party payer is required to give a provider under
division (B) of this section shall be made in writing accordance with division (C)(2) of this section
and shall specify all of the following:
        (1)(a) The full name of the beneficiary who received the health care services for which
overpayment was made;
        (2)(b) The date or dates the services were provided;
        (3)(c) The amount of the overpayment;
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        (4)(d) The claim number or other pertinent numbers;
        (5)(e) A detailed explanation of basis for the third-party payer's determination of
overpayment;
        (6)(f) The method in which payment was made, including, for tracking purposes, the date of
payment and, if applicable, the check number;
        (7)(g) That the provider may appeal the third-party payer's determination of overpayment, if
the provider responds to the notice within thirty sixty days;
        (8)(h) The method by which recovery of the overpayment would be made, if recovery
proceeds under division (B) of this section.
        (2) A third-party payer shall give a provider a notice of overpayment in writing. If the third-
party payer and provider use an agreed-upon established electronic notification system, the third-
party payer shall notify the provider electronically through that system.
        (D) Any provision of a contractual arrangement entered into between a third-party payer and
a provider or beneficiary that is contrary to divisions (A) to (C) of this section is unenforceable.
       SECTION 2. That existing section 3901.388 of the Revised Code is hereby repealed.
Am. Sub. S. B. No. 162  136th G.A.
     Speaker ___________________ of the House of Representatives.
  President ___________________ of the Senate.
Passed ________________________, 20____
Approved ________________________, 20____
  Governor.
Am. Sub. S. B. No. 162  136th G.A.
  The section numbering of law of a general and permanent nature is
complete and in conformity with the Revised Code.
  Director, Legislative Service Commission.
Filed in the office of the Secretary of State at Columbus, Ohio, on the ____
day of ___________, A. D. 20____.
  Secretary of State.
File No. _________       Effective Date ___________________