2024 24LSO-0030
STATE OF WYOMING Working Draft
0.5
DRAFT ONLY
NOT APPROVED FOR
INTRODUCTION
HOUSE BILL NO.
Health insurance-reimbursement of overpayments.
Sponsored by: Joint Labor, Health & Social Services Interim Committee
A BILL
for
1 AN ACT relating to health insurance; specifying a time
2 limit to seek reimbursement for health insurance
3 overpayments; and providing for an effective date.
4
5 Be It Enacted by the Legislature of the State of Wyoming:
6
7 Section 1. W.S. 26-15-137 is created to read:
8
9 26-15-137. Time limit to seek reimbursement for
10 health insurance overpayments.
11
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1 An action or request for reimbursement of any overpayment
2 of a health insurance claim to a health care provider
3 pursuant to any health insurance contract shall be brought
4 not more than two (2) years after the date the claim was
5 paid. No insurer, assignee of the insurer, or other person,
6 whether acting for himself or another in connection with a
7 health insurance transaction, shall make any claim or seek
8 recovery for reimbursement of any overpayment to a health
9 care provider pursuant to any health insurance contract
10 more than two (2) years after the date the claim was paid,
11 unless the claim was fraudulent.
12
13 ***********************************************************
14 *******************
15 STAFF COMMENT
16
17 The Committee heard testimony that the look-back period for
18 insurers to seek reimbursement from health care providers
19 is ten years and instructed LSO to draft a bill amending
20 the look-back period to two years. However, there does not
21 appear to be a Wyoming statute specifically setting forth
22 the look-back period for these types of overpayments.
23
24 The ten-year period likely stems from the statute of
25 limitations for actions based upon a written contract. W.S.
26 1-3-105(a)(i) (“Civil actions other than for the recovery
27 of real property can only be brought within the following
28 periods after the cause of action accrues: (i) Within ten
29 (10) years, an action upon a specialty or any contract,
30 agreement or promise in writing[.]”).
31
32 The Legislature may specify a different statute of
33 limitations. W.S. 1-3-102 (“Civil actions can only be
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1 commenced within the periods prescribed in this chapter,
2 after the cause of action accrues, but where a different
3 limitation is prescribed by statute, that shall govern.”).
4
5 This bill draft is modeled on Kentucky Statute 304.14-375,
6 which is part of the Kentucky Insurance Code and sets forth
7 a simple two-year time limit to seek reimbursement of
8 health insurance overpayments, unless the claim was false
9 or fraudulent.
10
11 In Wyoming, the statute of limitations for fraud is four
12 years. W.S. 1-3-105(a)(iv)(D). W.S. 1-3-106 provides that a
13 cause of action for fraud accrues when the fraud is
14 discovered. The Wyoming Supreme Court has interpreted W.S.
15 1-3-106 to mean that “a claim for fraud accrues when a
16 plaintiff actually discovers the fraud or could have
17 discovered the fraud through the exercise of reasonable
18 diligence.” Robert L. Kroenlein Tr. v. Kirchhefer, 2015 WY
19 127, ¶ 29, 357 P.3d 1118, 1128 (Wyo. 2015).
20
21 Look-back statutes in other states (sometimes referred to
22 as "recoupment" statutes) are often complex. Some states:
23
24 • Define terms related to requests for reimbursement.
25
26 o See, e.g., Ala. Code 27-1-17(b); Ariz. Rev.
27 Stat. 20-3101; Del. Code Ann. tit. 18, 2730(e),
28 (f); N.H. Rev. Stat. Ann. 420-J;8-b(I); Utah
29 Code Ann. 31A-26-301.6(1); Vt. Stat. Ann. tit.
30 18, 9418(a); Va. Code Ann. 38.2-3407.15(A); W.
31 Va. Code Ann. 33-45-1.
32
33 • Require the insurer to give the provider notice as
34 specified.
35
36 o See, e.g., Ala. Code 27-1-17(g); Del. Code Ann.
37 tit. 18, 2730(a); Fla. Stat. Ann. 627.6131(6);
38 N.H. Rev. Stat. Ann. 420-J;8-b(III); Ohio Rev.
39 Code Ann. 3901.388(C); S.C. Code Ann. 38-59-
40 250(A); Vt. Stat. Ann. tit. 18, 9418(h); Va.
41 Code Ann. 38.2-3407.15(B)(7)-(8); Wash. Rev.
42 Code 48.43.600(1), (2).
43
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1 • Establish a time limit for the provider to respond to
2 the insurer’s request for reimbursement or specify
3 that if the provider does not contest the request for
4 reimbursement then the request is deemed accepted.
5
6 o See, e.g., Ala. Code 27-1-17(g); Fla. Stat. Ann.
7 627.6131(6); Ohio Rev. Code Ann. 3901.388(B);
8 Wash. Rev. Code 48.43.600(1), (2).
9
10 • Require the insurer to provide a method for the
11 provider to challenge the request for reimbursement.
12
13 o See, e.g., Ariz. Rev. Stat. 20-3102(F); Del.
14 Code Ann. tit. 18, 2730(b); Ohio Rev. Code Ann.
15 3901.388(B); Utah Code Ann. 31A-26-301.6(9); Va.
16 Code Ann. 38.2-3407.15(B)(12).
17
18 • Carve out exceptions to the look-back period or
19 provide a different look-back period for specified
20 circumstances (e.g., fraud, misrepresentation,
21 coordination of benefits, duplicate payments, the
22 provider did not deliver the services, required by a
23 self-insured plan, required by a state or federal
24 government program, Medicare, etc.).
25
26 o See, e.g., Ala. Code 27-1-17(e), (f); Ariz. Rev.
27 Stat. 20-3102(I); Del. Code Ann. tit. 18,
28 2730(c); Fla. Stat. Ann. 627.6131(6); Ind. Code
29 Ann. 27-8-5.7-10(c); Miss. Code Ann. 83-41-
30 219(3); Mont. Code Ann. 33-22-150(4); N.H. Rev.
31 Stat. Ann. 420-J;8-b(II); Ohio Rev. Code Ann.
32 3901.388(A); S.C. Code Ann. 38-59-250(B); Utah
33 Code Ann. 31A-26-301.6(14); Vt. Stat. Ann. tit.
34 18, 9418(i); Va. Code Ann. 38.2-3407.15(B)(7);
35 Wash. Rev. Code Ann. 48.43.600(1), (3), (7); W.
36 Va. Code Ann. 33-45-2(7).
37
38 • Specify that conflicting contractual provisions are
39 unenforceable or that the statutory requirements
40 cannot be waived by contract.
41
42 o See, e.g., Ala. Code 27-1-17(h); Del. Code Ann.
43 tit. 18, 2730(g); Fla. Stat. Ann. 627.6131(10);
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1 Ohio Rev. Code Ann. 3901.388(D); Wash. Rev. Code
2 48.43.600(4).
3
4 • Allow the insurer and provider to agree through
5 contract on a length of time to adjust or request
6 adjustment of payment.
7
8 o See, e.g., Ariz. Rev. Stat. 20-3102(I).
9
10 The Committee inquired whether pharmacy benefit managers
11 would be covered by an amendment to the look-back period
12 for health care providers. There appears to be a separate
13 two-year look-back period applicable to pharmacy benefit
14 managers. W.S. 26-52-103(a)(iii) provides: "Any pharmacy
15 benefit manager or person acting on behalf of a pharmacy
16 benefit manager who conducts an audit of a pharmacy shall
17 follow the following procedure: . . . (iii) Limit the
18 period covered by the audit to not more than two (2) years
19 from the date that an audited claim was adjudicated[.]"
20
21 ***********************************************************
22 *******************
23
24 Section 2. This act shall apply to health insurance
25 overpayments made on or after the effective date of this
26 act.
27
28 Section 3. This act is effective July 1, 2024.
29
30 (END)
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