On Nov. 4, 2016, Pennsylvania Gov. Tom Wolf signed Act 146 of 2016, which will ban retroactive denial of reimbursement by insurers to health care providers under certain circumstances.
The legislation—originally introduced as House Bill 2241 by Rep. Karen Boback (R-117th District)—was unanimously passed by both the PA House and Senate before making its way to the governor's desk. It will require that an insurer cannot retroactively deny reimbursement as a result of an overpayment determination more than 24 months after the date the insurer initially paid the health care provider.
There are four exceptions that authorize an insurer to retroactively deny beyond the 24-month period:
- The information submitted to the insurer constitutes fraud, waste or abuse.
- The claim submitted to the insurer was a duplicate claim.
- Denial was required by a Federal or State government plan.
- Services subject to coordination of benefits with another insurer, the medical assistance program or the Medicare program.
The new law addresses a significant pain point for many physician practices concerning the retroactive denial of health insurance claims. It is an issue that the Pennsylvania Medical Society (PAMED) has been working to address for several years.
The window of time that the Act will restrict this practice to is a significant improvement from current retroactive review practices. PAMED supported this compromise legislation. PAMED worked closely with the Pennsylvania Orthopaedic Society, who led advocacy efforts on this issue.