DE HB212

Reduces the time period for health insurers and health plans to initiate overpayment recovery efforts from 24 months to 12 months after the original claim payment was made

Requires health insurers to demonstrate fraud, abuse, or intentional misconduct through physical review or review of claims data before exempting overpayment recovery from the time limit, replacing the previous "reasonable belief" standard

Prohibits the use of extrapolation in calculating recoupment or penalties for audits, requiring overpayment findings to be based on actual overpayments rather than projections based on similar diagnoses or prescriptions

Mandates that pharmacy benefit managers provide written notice to pharmacies identifying the specific error and justification when engaging in recoupment or chargeback efforts

Tightens the exemptions to pharmacy audit rules by requiring definitive proof of fraud or misconduct through physical review or investigative methods before the Pharmacy Audit Integrity Program protections become inapplicable