Section 376.1345

Title XXIV BUSINESS AND FINANCIAL INSTITUTIONS

Chapter 376

Effective - 28 Aug 2024, 3 histories   

  376.1345.  Method of reimbursement not to require fee, discount, or remuneration — notification requirements — electronic funds transfer, when — overpayment, procedure — violation, penalty. — 1.  As used in this section, unless the context clearly indicates otherwise, terms shall have the same meaning as ascribed to them in section 376.1350.

  2.  No health carrier, nor any entity acting on behalf of a health carrier, shall restrict methods of reimbursement to health care providers for health care services to a reimbursement method requiring the provider to pay a fee, discount the amount of their claim for reimbursement, or remit any other form of remuneration in order to redeem the amount of their claim for reimbursement.

  3.  (1)  If a health carrier proposes to initiate or change the method used to reimburse a health care provider to a method of reimbursement that will require the health care provider to pay a fee, discount the amount of its claim for reimbursement, or remit any other form of remuneration to the health carrier or any entity acting on behalf of the health carrier in order to redeem the amount of its claim for reimbursement, as described in subsection 2 of this section, the health carrier or an entity acting on its behalf shall first receive approval from the health care provider before reimbursing the health care provider with such payment method.

  (2)  If a health carrier is currently reimbursing a health care provider with a payment method described in subsection 2 of this section, the health care provider may send one notice to the health carrier for all the health care provider's patients covered by such health carrier stating that the health care provider declines to be reimbursed with a payment method described in subsection 2 of this section.  Such notice shall remain in effect for the duration of the contract unless the health care provider requests otherwise in the manner described in paragraph (b) of subdivision (3) of this subsection.  All payments made by the health carrier to the health care provider after receipt of the notice declining to be reimbursed with a payment method described in subsection 2 of this section shall not require the health care provider to pay a fee, discount the amount of the provider's claim for reimbursement, or remit any other form of remuneration in order to redeem the amount of the provider's claim for reimbursement.

  (3)  A health carrier that proposes to reimburse a health care provider with a payment method described in subsection 2 of this section shall:

  (a)  Notify such health care provider of the fee, discount, or other remuneration required to receive reimbursement through the new or different reimbursement method; and

  (b)  In such notice, provide clear instructions to the health care provider as to how to select the payment method described in subsection 2 of this section, and upon request by the health care provider such payment method shall be allowed to reimburse the provider until the provider requests otherwise.

  4.  A health carrier shall allow the provider to select to be reimbursed by an electronic funds transfer through the Automated Clearing House Network as required pursuant to 45 C.F.R. Sections 162.925, 162.1601, and 162.1602, and if the provider makes such selection, the health carrier shall use such reimbursement method to reimburse the provider until the provider requests otherwise.

  5.  An amount a health carrier claims was overpaid to a provider may only be collected, withheld, or recouped from the provider, or third party that submitted the provider's claim under the third party's provider identification number, to whom the overpaid amount was originally paid.  The notice of withholding or recoupment by a health carrier shall also inform the provider or third party of the health care service, date of service, and patient for which the recoupment is being made.

  6.  Violation of this section shall be deemed an unfair trade practice under sections 375.930 to 375.948.

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(L. 2019 S.B. 514, A.L. 2020 H.B. 1682, A.L. 2024 S.B. 1359)