HB1437 (2016) Detail

Relative to health insurance fraud and abuse reporting.

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AN ACT\trelative to health insurance fraud and abuse reporting.


SPONSORS:\tRep. Sad, Ches. 1


COMMITTEE:\tCommerce and Consumer Affairs






\tThis bill requires health insurance carriers to establish a fraud and abuse detection system and to investigate any health insurance claim or series of claims for services that are suspected to be the result of health care provider billing fraud and abuse.  Under this bill, the health insurance carrier shall report suspected fraud or abuse to the fraud investigation unit.  


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Explanation:\tMatter added to current law appears in bold italics.

\t\tMatter removed from current law appears [in brackets and struckthrough.]

\t\tMatter which is either (a) all new or (b) repealed and reenacted appears in regular type.






In the Year of Our Lord Two Thousand Sixteen


AN ACT\trelative to health insurance fraud and abuse reporting.


Be it Enacted by the Senate and House of Representatives in General Court convened:


\t1  New Section; Unfair Insurance Trade Practices; Health Insurance Fraud and Abuse Reporting.  Amend RSA 417 by inserting after section 28 the following new section:

\t417:28-a  Health Insurance Fraud and Abuse Reports Required.

\t\tI.  A health insurance carrier or third party administrator shall  investigate any health insurance claim, or series of claims, for services that are suspected to be the result of health care provider billing fraud or abuse.  Health insurance carriers shall establish a fraud and abuse detection system which shall be documented and approved by the department annually.  The carrier detection system shall be able to identify the following:

\t\t\t(a)  An impossible number of services performed by a provider;

\t\t\t(b)  Situations where multiple services are provided to the same patient on the same day in highly variable geographic areas;

\t\t\t(c)  An unlikely duplication of services by the same or differing providers, billing for services that are more expensive than what the patient actually received;

\t\t\t(d)  Misrepresentation of non-covered treatments as medically necessary covered services; and

\t\t\t(e)  Falsification of a patient's diagnosis to justify additional services.

\t\tII.  Health insurance claims that are considered to be the result of provider fraud or abuse and require carrier investigation shall include, but are not limited to:  those services reported to the carrier by covered members that the member did not receive; services identified by the carrier through internal fraud detection systems; and services identified by the department.

\t\tIII.  Health fraud and abuse reports shall be made to the insurance fraud investigation unit established in RSA 417:23, within 60 days or within a shorter period under such circumstances as the commissioner may prescribe by rule adopted pursuant to RSA 541-A.  No waiver of any such regulated person’s or entity’s applicable privilege or claim of confidentiality in the documents, materials, or information shall occur as a result of a disclosure to the unit.  The report shall be made on a form prescribed by the commissioner and shall contain the information requested and such additional information as the unit may require.  The unit shall review the report and select claims that warrant further investigation.  In the absence of fraud or malice, no public official or insurance company or person who furnishes information on behalf of the insurance company shall be liable for damages in a civil action or subject to criminal prosecution for any oral or written statement made or any other action taken that is necessary to supply information required pursuant to this section.

\t\tIV.  Failure to make a report or to maintain a system for detecting fraud under this section shall constitute a violation of this chapter.

\t\tV.  The commissioner shall adopt rules, pursuant to RSA 541-A, that specify reporting obligations, form and content of forms required under this section, and guidelines for fraud detection systems required under this section.

\t2  Effective Date.  This act shall take effect January 1, 2017.