SB 162 — Regards timing of health insurer recoupment from providers

As(136th PassedGeneralAssembly) by(Amended theSubstitute Senate 136thBill GeneralNumber Assembly162) RegularANACT SessionTo Sub.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;

Am.

Sub.

162 2025-2026136th SenatorG.A. Blessing Cosponsors:

Senators(4)(d) Liston,The Blackshear,claim Chavez,number Cirino,or Craig,other DeMora,pertinent Hicks-numbers; Hudson, Ingram, Johnson, Reineke, Smith, Weinstein To amend section 3901.388 of the Revised Code 1 regarding the timeframe for health insurer 2 recoupment from health care providers.

3(5)(e) BEA ITdetailed ENACTEDexplanation BYof THEbasis GENERALfor ASSEMBLYthe OFthird-party THEpayer's STATEdetermination OFof OHIO:overpayment;

Section(6)(f) 1.The method in which payment was made, including, for tracking purposes, the date of payment and, if applicable, the check number;

(7)(g) That sectionthe 3901.388provider ofmay appeal the Revisedthird-party Codepayer's bedetermination 4of amendedoverpayment, if the provider responds to readthe asnotice follows:within thirty sixty days;

5(8)(h) Sec.The method by which recovery of the overpayment would be made, if recovery proceeds under division (B) of this section.

3901.388.(2) A third-party payer shall give a provider a notice of overpayment in writing.

(A)(A)(1)If Athe paymentthird- madeparty by a third-party 6 payer toand a provider inuse accordancean withagreed-upon sectionsestablished 3901.381electronic tonotification 7system, 3901.386 of the Revisedthird- Codeparty payer shall benotify consideredthe finalprovider twoelectronically 8through yearsonethat yearsystem. after payment is made.

After(D) thatAny date,provision theof amounta 9contractual ofarrangement theentered paymentinto isbetween nota subjectthird-party topayer adjustment,and excepta inprovider theor casebeneficiary 10that is contrary to divisions (A) to (C) of fraudthis bysection theis provider.unenforceable.

11SECTION (2)2. No third-party payer shall change its payment, audit, 12 or review timelines during the contract period.

13That (B)existing Asection third-party3901.388 payer may recover the amount of any part 14 of a payment that the third-partyRevised payerCode determines to be an 15 overpayment if the recovery process is initiatedhereby notrepealed. later than 16 two years one year after the payment was made to the provider.

17Am. The third-party payer shall inform the provider of its 18 Sub.

Sub.

162 Page136th 2G.A. As Passed by the Senate determination of overpayment by providing notice in accordance 19 with division (C) of this section.

TheSpeaker third-party___________________ payerof shall 20 give the providerHouse anof opportunityRepresentatives. to appeal the determination and 21 shall not charge the provider a fee for an appeal.

IfPresident the___________________ 22 provider fails to respond to the notice sooner than thirty 23 within sixty days after the notice is made, elects not to appeal 24 the determination, or appeals the determination but the appeal 25 is not uphelddenied, the third-party payer may initiate recovery 26 of the overpayment.Senate.

27Passed When________________________, a20____ providerApproved has________________________, failed20____ toGovernor. make a timely response to 28 the notice of the third-party payer's determination of 29 overpayment, the third-party payer may recover the overpayment 30 by deducting the amount of the overpayment from other payments 31 the third-party payer owes the provider or by taking action 32 pursuant to any other remedy available under the Revised Code.

33Am. When a provider elects not to appeal a determination of 34 overpayment or appeals the determination but the appeal is not 35 uphelddenied, the third-party payer shall permit a provider to 36 repay the amount by making one or more direct payments to the 37 third-party payer or by having the amount deducted from other 38 payments the third-party payer owes the provider.

39Sub. (C)(C)(1) The notice of overpayment a third-party payer is 40 required to give a provider under division (B) of this section 41 shall be made in writing accordance with division (C)(2) of this 42 section and shall specify all of the following:

43 (1)(a) The full name of the beneficiary who received the 44 health care services for which overpayment was made;