Bill > HB4028

This bill, effective 91 days after the legislative session ends, aims to regulate how insurers, coordinated care organizations (CCOs), and the Oregon Health Authority (OHA) conduct audits of behavioral health treatment providers, defining "audit" as a review of records or claims, and "behavioral health treatment" as mental health and substance use disorder services excluding those in hospitals or hospital-affiliated clinics. Insurers must provide clear, plain-language descriptions of claim requirements and notify providers 30 days before changes, and audits of paid claims are limited to 12 months prior (or six years for suspected fraud) and must be completed within 180 days, with findings reviewed by a behavioral health professional, and cannot overturn prior medical necessity determinations unless the patient was uninsured. Insurers can only initiate audits if there's a high probability of error and recoup payments only for specifically identified errors, and providers are given at least 30 days to correct errors and can use a three-year repayment plan, with insurers prohibited from charging audit costs or incentivizing auditors to find errors. CCOs and OHA have similar audit limitations, with a five-year lookback period for paid claims unless fraud is suspected, and audits must be completed within 180 days and conducted by a behavioral health professional. Additionally, certain carriers must annually report to the Department of Consumer and Business Services (DCBS) on their compliance with behavioral health parity requirements, ensuring that limitations on behavioral health benefits are comparable to and applied no more stringently than those for medical and surgical benefits, with specific reporting requirements on nonquantitative treatment limitations, denial rates, and reimbursement rates, and this bill's provisions apply to audits initiated on or after January 1, 2027.

Health and Social Services

https://olis.oregonlegislature.gov/liz/2026R1/Measures/Overview/HB4028