Vermont § 640a - Medical bills; payment; dispute

§ 640a. Medical bills; payment; dispute

• (a) Not later than 30 days following receipt of a bill from a health care provider for
  medical, surgical, hospital, nursing services, supplies, prescription drugs, or durable
  medical equipment provided to an injured employee, an employer or insurance carrier
  shall do one of the following: (1) Pay or reimburse the bill. (2) Provide written notification to the injured employee, the health care provider, and
  the Commissioner that the medical bill is contested or denied. The notice shall include
  specific reasons supporting the contest or denial, a description of any additional
  information needed by the employer or insurance carrier to determine liability for
  the medical bill, and a request that such information be submitted to the employer
  or insurance carrier within 30 days following receipt of the notice. (b) Disputes regarding payment of a medical bill may be filed with the Commissioner by
  the injured employee or the health care provider. Disputes regarding payment of a
  medical bill or interest on that bill shall be determined by the Commissioner or,
  at the option of either party, be settled by arbitration in accordance with the Commercial
  Rules of the American Arbitration Association. The decision of an arbitrator shall
  be provided to the Commissioner, and the award may be entered as a judgment in a court
  of jurisdiction. (c) If a medical bill was denied on the basis that the employer or insurance carrier was
  not provided with sufficient information to determine liability for payment pursuant
  to subdivision (a)(2) of this section, the employer or insurance carrier has 30 days
  following receipt of the additional information requested to pay or deny payment of
  the bill. (d) Medical bills shall be paid within the time required in this section or according
  to the time requirements specified in a contract between the health care provider
  and the employer or insurance carrier. (e) Interest shall accrue on an unpaid medical bill at the rate of 12 percent per annum
  calculated as follows: (1) From the first calendar day following 30 days after the date the medical bill is received
  by the employer or insurance carrier for: (A) a medical bill that was not denied; or (B) a medical bill that was denied and written notice was not provided or not provided
  within 30 days after receipt of the medical bill. (2) For a medical bill that was denied based on insufficient information and notice was
  provided in compliance with subdivision (a)(2) of this section, from the first calendar
  day following 30 days after receipt of additional information sufficient to determine
  liability for payment. (3) For a medical bill that was denied and notice was provided in compliance with subsection
  (a) of this section, from the first calendar day following 30 days after the date
  of a final arbitration award, judgment, or administrative order awarding payment of
  the disputed medical bill. (4) For a medical bill that is paid in accordance with a contract between the health care
  provider and the employer or insurance carrier, from the day following the contract
  payment period or as otherwise specified in the contract. (f)(1) A health care provider shall submit a medical bill accompanied by medical documentation
  to the employer or insurance carrier within six months after the date the health care
  provider had actual knowledge that the services provided were related to a claim under
  this chapter. (2) As used in this subsection (f), “medical documentation” means documentation that describes
  an injury and the treatment provided and includes all relevant treatment notes, medical
  records, and diagnostic codes with sufficient detail to review the medical necessity
  of the service and the appropriateness of the fee charged. (3) Failure to submit the bill within six months does not bar payment unless the employer
  or insurance carrier is prejudiced by the delay. The Commissioner may extend the six-month
  limit if the Commissioner determines that the delay resulted from circumstances outside
  the control of the health care provider. (g) A medical bill shall be submitted in a legible form with every field or data element
  relevant to the treatment completed and treatment coding that conforms to the criteria
  of the National Correct Coding Initiative. The medical bill shall be submitted in
  any one of the following electronic or paper formats: (1) CMS 1500 or its electronic equivalent for medical services. (2) UB04 or its electronic equivalent for hospital inpatient and outpatient services. (3) ADA J515 or its electronic equivalent for dental services. (h) The Commissioner may assess penalties as provided in section 688 of this title against an employer or insurance carrier that fails to comply with the provisions
  of this section and may also refer to the Commissioner of Financial Regulation any
  employer or insurance carrier that neglects or refuses to pay medical bills as required
  by this section. (i) Any interest or penalty paid by an employer or insurance carrier under this chapter
  shall be excluded from the claims data reported pursuant to 8 V.S.A. § 4687. (j) An employer or insurance carrier shall not impose on any health care provider any
  retrospective denial of a previously paid medical bill or any part of that previously
  paid medical bill, unless: (1) The employer or insurance carrier has provided at least 30 days’ notice of any retrospective
  denial or overpayment recovery or both in writing to the health care provider. The
  notice must include: (A) the injured employee’s name; (B) the service date; (C) the payment amount; (D) the proposed adjustment; and (E) a reasonably specific explanation of the proposed adjustment. (2) The time that has elapsed does not exceed 12 months from the later of the date of
  payment of the previously paid medical bill or the date of a final determination of
  compensability. (k) The retrospective denial of a previously paid medical bill shall be permitted beyond
  12 months from the later of the date of payment or the date of a final determination
  of compensability for any of the following reasons: (1) The employer or insurance carrier has a reasonable belief that fraud or other intentional
  misconduct has occurred. (2) The medical bill payment was incorrect because the health care provider was already
  paid for the health services identified in the medical bill. (3) The health care services identified in the medical bill were not delivered by the
  health care provider. (4) The medical bill payment is the subject of adjustment with another workers’ compensation
  or health insurer. (5) The medical bill is the subject of legal action. (l)(1) For purposes of subsections (j) and (k) of this section, for routine recoveries as
  described in subdivisions (A) through (J) of this subdivision (1), retrospective denial
  or overpayment recovery of any or all of a previously paid medical bill shall not
  require 30 days’ notice before recovery may be made. A recovery shall be considered
  routine only if one of the following situations applies: (A) duplicate payment to a health care provider for the same professional service; (B) payment with respect to an individual for whom the employer or insurance carrier is
  not liable as of the date the service was provided; (C) payment for a noncovered service, not to include services denied as not medically
  necessary, experimental, or investigational in nature, or services denied through
  a utilization review mechanism; (D) erroneous payment for services due to employer or insurance carrier administrative
  error; (E) erroneous payment for services where the medical bill was processed in a manner inconsistent
  with the data submitted by the health care provider; (F) payment where the health care provider provides the employer or insurance carrier
  with new or additional information demonstrating an overpayment; (G) payment to a health care provider at an incorrect rate or using an incorrect fee schedule; (H) payment of medical bills for the same injured employee that are received by the employer
  or insurance carrier out of the chronological order in which the services were performed; (I) payment where the health care provider has received payment for the same services
  from another payer whose obligation is primary; or (J) payments made in coordination with a payment by a government payer that require adjustment
  based on an adjustment in the government-paid portion of the medical bill. (2) Notwithstanding the provisions of subdivision (1) of this subsection, recoveries which,
  in the reasonable business judgment of the employer or insurance carrier, would be
  likely to affect a significant volume of claims or accumulate to a significant dollar
  amount shall not be deemed routine, regardless of whether one or more of the situations
  in subdivisions (1)(A) through (J) of this subsection apply. (3) Nothing in this subsection shall be construed to affect the time frames established
  in subdivision (j)(2) or subsection (k) of this section. (Added 2009, No. 61, § 27; amended 2023, No. 85 (Adj. Sess.), § 129, eff. July 1, 2024.)