Bill > HB212

This bill amends Delaware's health insurance and pharmacy benefit manager (PBM) regulations to modify overpayment recovery and audit practices. Specifically, the bill changes the time limit for health insurers to initiate overpayment recovery from 24 to 12 months after the original claim payment, with exceptions for cases involving fraud, self-insured plans, or government plans. The bill clarifies that overpayment recovery efforts are considered "initiated" when an insurer first identifies a payment error through an initial audit report. Additionally, the bill prohibits insurers from basing overpayment findings on projections or extrapolations, requiring actual documented overpayments. For pharmacy benefit managers, the bill introduces a new requirement that they must provide written notice to pharmacies when attempting recoupment, explaining the specific error in claim processing. The bill also refines the definition of investigative audits exempt from standard regulations, specifying conditions such as evidence of fraud, criminal wrongdoing, or state-conducted audits. These changes aim to provide more transparency and fairness in how health insurers and PBMs conduct financial reviews and recover alleged overpayments.

Business and Industry

https://legis.delaware.gov/BillDetail?LegislationId=142479