§1838. Recoupment of health insurance claims payments

A. As used in this Section, "recoupment" shall mean a reduction, offset, adjustment, or other act to lower or lessen the payment of a claim or any other amount owed to a health care provider for any reason unrelated to that claim or other amount owed to a health care provider.

B. Prior to any recoupment unrelated to a claim for payment of medical services provided by a health care provider or any other amount owed by a health insurance issuer to a health care provider, the health insurance issuer shall provide the health care provider written notification that includes the name of the patient, the date or dates of health care services rendered, and an explanation of the reason for recoupment. A health care provider shall be allowed thirty days from receipt of written notification of recoupment to appeal the health insurance issuer's action and to provide the health insurance issuer the name of the patient, the date or dates of health care services rendered, and an explanation of the reason for the appeal.

C.(1) When a health care provider fails to respond timely and in writing to a health insurance issuer's written notification of recoupment, the health insurance issuer may consider the recoupment accepted.

(2) If a recoupment is accepted, the health care provider may remit the agreed amount to the health insurance issuer at the time of any written notification of acceptance or may permit the health insurance issuer to deduct the agreed amount from future payments due to the health care provider.

D.(1) If a health care provider disputes a health insurance issuer's written notification of recoupment and a contract exists between the health care provider and the health insurance issuer, the dispute shall be resolved according to the general dispute resolution provisions in the contract.

(2) If a health care provider disputes a health insurance issuer's written notification of recoupment and no contract exists between the health care provider and the health insurance issuer, the dispute shall be resolved as any other dispute under Civil Code Article 2299 et seq.

E. If the recoupment directly affects the payment responsibility of the insured, the health insurance issuer shall provide at the same time a revised explanation of benefits to the health care provider and the covered person for whose claim the recoupment is being made. Unless the recoupment of a health insurance claim payment directly affects the payment responsibility of the insured, such recoupment shall not result in any increased liability of an insured.

F.(1) A health insurance issuer shall not retroactively deny, adjust, or seek recoupment or refund of a paid claim for healthcare expenses submitted by a healthcare provider for healthcare services rendered in good faith and pursuant to the benefit plan for any reason after the expiration of eighteen months from the date the initial claim was paid.

(2) This Subsection shall not be construed to supersede any provision of law that prescribes a time period less than eighteen months for the retroactive denial of payment or recoupment of monies paid for a claim or the reconsideration of the validity of a claim.

G. The provisions of this Section shall not apply to the Office of Group Benefits.

Acts 2001, No. 1096, §1; Acts 2003, No. 672, §1; Redesignated from R.S. 22:250.38 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2018, No. 66, §1.