Pennsylvania Orthopaedic Society Supports Prohibition of Insurer Retroactive Denials

HARRISBURG, Pa. - Feb. 23, 2015 - PRLog -- Pennsylvania Orthopaedic Society (POS)leaders today joined Senator David Argall (R-29) in support of his newly introduced legislation that would protect healthcare providers from post-payment reviews by limiting insurance companies’ ability to retroactively deny reimbursement.

This legislation would protect healthcare providers from post-payment reviews by requiring insurance carriers to review treatment plans, claim forms and billing statements within a reasonable amount of time. In addition, the bill specifies that an insurer may only retroactively deny reimbursement during the 12 month period following the date the insurer paid the claim.

“As amazing as it may seem, current law allows an insurer to subject physicians to recoupment of paid claims that are two, three or even four years old,” said POS President Thomas Muzzonigro, MD.  “Worst yet, an insurer may simply reduce physicians’ future payments by the alleged overpayment amount the insurer determined.  Unfortunately, our only recourse is to appeal that decision to the insurer who conducted the retroactive review.  Senator Argall’s legislation will remedy this intolerable insurer tactic.”

Current law contains no limit on an insurer’s ability to retroactively review paid claims.  Insurer contracts generally provide that a healthcare provider must submit a claim within 12 months of treatment or not be paid for care rendered.  Insurers, on the other hand, reserve the right to retroactively review claims with no limit.  This practice is commonly known as a recovery or “claw-back”.  “Senator Argall’s legislation will remedy this insurer overreach by limiting retroactive reviews to an equivalent 12 month period.  That is reasonable and that is just,”    Muzzonigro stated.

Similar legislation to Senator Argall’s initiative passed the state House of Representatives in 2007 (HB 1000 of 2007) on a 203 to 0 vote.  Healthcare providers’ efforts to revive the issue have been met with stiff opposition from the insurance industry ever since.  This session, an expanded coalition of healthcare provider organizations that includes physicians, chiropractors and hospitals aims to change this dynamic in the General Assembly.

Advocating for excellence in the practice of orthopaedic medicine, POS is a professional medical specialty organization representing more than 1,000 orthopaedic surgeons across Pennsylvania.  For more information on the importance of bone, joint and muscle health at every age, visit www.paorthosociety.org.

#     #     #