AN ACT TO AMEND TITLE 18 OF THE DELAWARE CODE RELATING TO OVERPAYMENT RECOVERY AND AUDIT PRACTICES.

Plain English Breakdown

The official source does not provide specific details on enforcement mechanisms and monitoring by regulatory bodies.

Changes to Health Insurance Overpayment Recovery and Pharmacy Audits

This act shortens the time limit for health insurers to recover overpayments from providers and pharmacies, requires written notice before pharmacy audits, and tightens rules on when certain audit exceptions can be used.

What This Bill Does

• Changes the period during which health insurance companies can ask for money back from healthcare providers or pharmacies from two years to one year after a claim is paid.
• Requires that any suspicion of fraud or misconduct must be based on actual evidence, not just a reasonable belief, before an exception to the overpayment recovery deadline can be used.
• Mandates written notice before pharmacy benefit managers (PBMs) conduct audits and limits when they can use exceptions to audit rules.

Who It Names or Affects

• Health insurance companies
• Healthcare providers and pharmacies
• Pharmacy benefit managers (PBMs)

Terms To Know

overpayment recovery

The process of getting back money that was paid in error to healthcare providers or pharmacies.

pharmacy audit integrity program

A set of rules for conducting audits on pharmacy claims to ensure they are fair and accurate.

Limits and Unknowns

• The bill does not specify the exact effective date.
• It is unclear how these changes will be enforced or monitored by regulatory bodies.

Official Summary Text

AN ACT TO AMEND TITLE 18 OF THE DELAWARE CODE RELATING TO OVERPAYMENT RECOVERY AND AUDIT PRACTICES.
This Substitute for House Bill No. 212 corrects a technical drafting error to underline new language contained in Section 2 of the Act, and is otherwise identical to House Bill No. 212, which does the following:

Section 1 of this Act amends the time period during which health insurers may initiate overpayment recovery efforts from 24 months to 12 months of a claim being paid. This Act also amends one of the exemptions to the overpayment recovery deadline to require an indication of fraud, abuse, or other intentional misconduct based on a physical review or review of claims data or statements as opposed to merely having a reasonable belief of such fraud, abuse or other intentional misconduct. It aligns requirements for provider-oriented clawbacks with those for pharmacies.

Section 2 of this Act requires written notice from pharmacy benefit managers or entities conducting pharmacy audits. Because Department examinations have indicated that PBMs misuse this provision in the law to conduct audits outside the parameters of the Pharmacy Audit Integrity Program, Section 3 of this Act amends the exclusions to the applicability of the pharmacy audit rules to require that pharmacy benefits managers have more definitive proof, based on physical review of claims data or other investigative methods, to believe misconduct has occurred before the rules related to the Pharmacy Audit Integrity Program become inapplicable to an investigative audit. This Act also makes technical corrections to existing law to conform to the requirements of the Delaware Legislative Drafting Manual.