Physicians and Advocates Tell Committee Recoupment Rules Hurt Practices; Bill Would Shorten Lookback and Bar Appeal Fees
Get AI-powered insights, summaries, and transcripts
Subscribe
Summary
Proponents of Senate Bill 162, including the Ohio State Medical Association and behavioral health representatives, told the Senate committee that insurers' "take backs" (recoupments) create financial instability for providers and that the bill would shorten the audit lookback period and bar insurers from charging providers to appeal recoupment.
Monica Hickel, vice president of advocacy for the Ohio State Medical Association (OSMA), and OSMA President John Bastulli, M.D., testified in support of Senate Bill 162, which OSMA says would limit insurers' ability to retroactively recoup payments and would prohibit insurers from charging providers for filing appeals of alleged overpayments.
"Take backs are also referred to claw backs in the healthcare space," Hickel said. She described the existing disparity in timelines: providers typically have 90 to 180 days to submit claims while insurers may audit and seek recoupment for up to 24 months after a payment was made. "Why should that time period for insurers to review claims be so much longer than the time period that they give providers to submit that type of information?" she asked.
Dr. Bastulli gave three clinical examples OSMA collected from physician practices that illustrate the effects of recoupments. In one, a claim for services on Nov. 3, 2021, paid Dec. 24, 2021, was audited in March 2022 and recouped in June 2022 even though the service had been preapproved, he said. In another, a service performed Aug. 8, 2023, was paid Sept. 5, 2023, but recouped on July 4, 2024, because the insurer said the patient's coverage had terminated before the date of service — though the plan had preapproved the service.
OSMA representatives and a witness from the National Association of Social Workers' Ohio chapter argued the bill would reduce administrative burden, protect small practices and help preserve access to care. Matthew Tippett of NASW-Ohio said late recoupments are a financial risk that discourages clinicians from accepting insurance or from opening private practices; he cited national workforce and salary data and said clawbacks have driven some providers to stop accepting insurance.
Committee members asked for data on audit rates and volumes. Hickel and Bastulli said they hear complaints frequently but did not provide a systematic audit rate; they offered anecdotes and said they would collect more data. The committee took proponent testimony; no formal vote occurred.