Health Insurance - Retroactive Denial of Reimbursement
HB 917 would narrow and add procedural requirements for when a health insurance carrier may retroactively deny reimbursement to a health care provider. Under the bill, retroactive denials would generally be allowed only in limited situations: for coordination-of-benefits claims involving another carrier, Maryland Medicaid, or Medicare within 18 months of payment, or for other claims only if the carrier has already provided training on reimbursement protocols, billing standards, and compliance requirements and the denial occurs within 3 months after the provider furnished the service. The bill also requires carriers to give providers a written explanation for any retroactive denial, including supporting documents or calculations, and in certain coordination-of-benefits cases the name and address of the entity responsible for payment.
The bill further prohibits carriers from retroactively denying reimbursement based on the outcome of the service, and it requires carriers to speak with the provider before denying reimbursement so the provider can explain the circumstances, rationale, or justification for the service. Carriers must consider the totality of the circumstances prospectively based on that explanation. In addition, any carrier that retroactively denies reimbursement must develop a training plan for providers on reimbursement protocols, billing standards, and compliance requirements. The bill preserves existing appeal rights for providers and insureds.
The bill would amend Section 15-1008(c) of the Insurance Article and apply to policies, contracts, and health benefit plans issued, delivered, or renewed on or after January 1, 2027. Its practical effect would be to limit carrier discretion, increase notice and documentation obligations, and create new provider-facing process requirements before retroactive reimbursement denials can be made.
The available context shows no recorded votes or committee testimony, so sentiment cannot be measured from debate or floor action. Based on the bill’s structure, it appears aimed at protecting providers from surprise recoupments and improving transparency, while still preserving carriers’ ability to correct certain payment errors and coordination-of-benefits issues. Likely points of contention would be the added administrative burden on insurers, the shortened denial window for some claims, and the requirement to consult with providers before denying reimbursement.
HB 917 would amend Maryland Insurance Article § 15-1008(c) to restrict when health insurers and other carriers may retroactively deny reimbursement to health care providers, expand the required contents of denial notices, and impose new training-plan obligations on carriers. It would affect carriers, health care providers, and insureds by limiting retroactive recoupments, especially outside coordination-of-benefits situations, and by preserving appeal rights under existing law.
There is no committee transcript or vote history in the provided record, so there is no direct evidence of support or opposition from hearings or floor debate. The bill’s design suggests a provider-protective and transparency-oriented approach, likely appealing to health care providers and potentially to patient advocates, while insurers may view it as increasing compliance and administrative burdens. Overall sentiment appears neutral-to-supportive in intent, but with likely insurer concerns about operational impact.
The main points of contention are likely to be the limits on carriers’ ability to recoup payments after the fact, the requirement to provide training and detailed written support for denials, and the mandate to confer with providers before denying reimbursement. Insurers may argue these provisions reduce flexibility and increase costs, while providers are likely to support the added notice, documentation, and procedural safeguards. The bill also draws a distinction between coordination-of-benefits cases and other retroactive denials, which may be debated as either a reasonable exception or an overly narrow one.