Bill Text: NY A08884 | 2011-2012 | General Assembly | Introduced
Bill Title: Provides for certain protections for health care providers under managed care contracts; requires certain contract provisions relating to fees, notice and termination; requires use of certain nationally recognized guidelines in billing and payment of claims; requires insurers to share in liability under certain circumstances; requires publication of certain information relating to fees.
Spectrum: Partisan Bill (Democrat 8-0)
Status: (Introduced - Dead) 2012-01-04 - referred to insurance [A08884 Detail]
Download: New_York-2011-A08884-Introduced.html
S T A T E O F N E W Y O R K
________________________________________________________________________
8884
I N A S S E M B L Y
(PREFILED)
January 4, 2012
___________
Introduced by M. of A. QUART -- read once and referred to the Committee
on Insurance
AN ACT to amend the insurance law, in relation to the rights of health
care providers under managed care contracts, rules relating to the
processing of health claims, and alleged overpayments to physicians
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
1 Section 1. Subsection (a) of section 3224-a of the insurance law, as
2 amended by chapter 237 of the laws of 2009, is amended to read as
3 follows:
4 (a) Except in a case where the obligation of an insurer or an organ-
5 ization or corporation licensed TO WRITE ACCIDENT OR HEALTH INSURANCE OR
6 LICENSED or certified pursuant to article forty-three or forty-seven of
7 this chapter or article forty-four of the public health law to pay a
8 claim submitted by a policyholder or person covered under such policy
9 ("covered person") or make a payment to a health care provider is not
10 reasonably clear, or when there is a reasonable basis supported by
11 specific information available for review by the superintendent that
12 such claim or bill for health care services rendered was submitted frau-
13 dulently, such insurer or organization or corporation shall pay the
14 claim to a policyholder or covered person or make a payment to a health
15 care provider within [thirty] FIFTEEN days of receipt of a claim or bill
16 for services rendered that is transmitted via the internet or electronic
17 mail, or [forty-five] THIRTY days of receipt of a claim or bill for
18 services rendered that is submitted by other means, such as paper or
19 facsimile. A HEALTH CARE PROVIDER WHO SUBMITS CLAIMS ELECTRONICALLY
20 SHALL HAVE THE OPTION OF GETTING PAID ELECTRONICALLY.
21 S 2. Section 3224-b of the insurance law, as added by chapter 551 of
22 the laws of 2006, subsection (b) as amended by chapter 237 of the laws
23 of 2009, is amended to read as follows:
24 S 3224-b. Rules relating to THE RIGHTS OF PHYSICIANS UNDER MANAGED
25 CARE CONTRACTS, the processing of health claims and [overpayments]
26 PAYMENTS to physicians. (a) [Processing of health care claims. This
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD08059-02-1
A. 8884 2
1 subsection is intended to provide uniformity and consistency in the
2 reporting of medical services and procedures as they relate to the proc-
3 essing of health care claims and is not intended to dictate reimburse-
4 ment policy] ALL AGREEMENTS BETWEEN HEALTH PLANS AND PHYSICIANS FOR THE
5 DELIVERY OF MEDICAL SERVICES TO HEALTH PLAN BENEFICIARIES MUST CONTAIN
6 AND CONFORM TO THIS SECTION'S RULES WITH RESPECT TO THE RIGHTS OF PHYSI-
7 CIANS UNDER MANAGED CARE CONTRACTS.
8 (1) For purposes of this section, a "health plan" shall be defined as
9 an insurer that is licensed to write accident and health insurance, or
10 that is licensed pursuant to article forty-three of this chapter or is
11 certified pursuant to article forty-four of the public health law.
12 (2) ALL CONTRACTS, INCLUDING AMENDMENTS THERETO, MUST BE SIGNED BY
13 BOTH PARTIES AND SHALL HAVE ATTACHED A COMPLETE FEE SCHEDULE APPROPRIATE
14 TO THE PHYSICIAN'S SPECIALTY.
15 (3) NO CONTRACT MAY COMPEL THE PHYSICIAN TO PARTICIPATE IN ANY FUTURE
16 PRODUCTS OFFERED BY THE PAYER.
17 (4) AN INSURER MAY ONLY TERMINATE THE CONTRACT PRIOR TO THE AGREED
18 UPON DATE OF EXPIRATION ON A FOR CAUSE BASIS. REFUSAL TO SIGN A CONTRACT
19 AMENDMENT SHALL NOT BE DEEMED CAUSE FOR TERMINATION.
20 (5) THERE SHALL BE A MINIMUM OF ONE HUNDRED FIFTY DAYS ADVANCED WRIT-
21 TEN NOTICE OF A CONTRACT'S NON-RENEWAL.
22 (6) INSURERS SHALL PROVIDE PHYSICIANS WITH A MINIMUM OF NINETY DAYS
23 ADVANCED WRITTEN NOTICE OF CHANGES IN POLICIES AND PROCEDURES EXCEPT
24 WHERE SUCH POLICY OR PROCEDURE CHANGE RESULTS IN A MATERIAL ADVERSE
25 IMPACT ON A PHYSICIAN'S ADMINISTRATIVE COSTS OR ON THE INSURER'S TOTAL
26 AGGREGATE LEVEL OF PAYMENT TO A PHYSICIAN, IN WHICH CASE SUCH A CHANGE
27 MAY ONLY BE EFFECTUATED THROUGH A CONTRACT AMENDMENT AGREED TO BY BOTH
28 PARTIES.
29 (7) INSURERS MAY NOT ASSIGN, LEASE OR CONVEY RIGHTS IN A CONTRACT WITH
30 THE PHYSICIAN TO AN UNRELATED PARTY WITHOUT THE PHYSICIAN'S WRITTEN
31 CONSENT IN EACH INSTANCE OF SUCH PROPOSED ASSIGNMENT, LEASE, OR CONVEY-
32 ANCE UNLESS SUCH ASSIGNMENT, LEASE, OR CONVEYANCE IS TO A PARENT, AFFIL-
33 IATE, OR SUBSIDIARY CORPORATION OR TO A TRANSFEREE OF ALL OR SUBSTAN-
34 TIALLY ALL OF SUCH INSURER'S ASSETS.
35 (8) INSURERS SHALL INDEMNIFY A PHYSICIAN FOR ANY DAMAGES FOR MEDICAL
36 LIABILITY RESULTING FROM THE PHYSICIAN'S COMPLIANCE WITH A PAYER'S
37 UTILIZATION REVIEW DECISIONS.
38 Subject to the provisions of paragraph [three] NINE of this
39 subsection, a health plan shall accept and initiate the processing of
40 all health care claims submitted by a physician pursuant to and consist-
41 ent with the current version of the American medical association's
42 current procedural terminology (CPT) codes, reporting guidelines and
43 conventions and the centers for medicare and medicaid services health-
44 care common procedure coding system (HCPCS) INCLUDING BUNDLED AND UNBUN-
45 DLED SERVICES.
46 [(3)] (9) Nothing in this section shall preclude a health plan from
47 determining that any such claim is not eligible for payment, in full or
48 in part, based on a determination that: (i) the claim is not complete as
49 defined by 11 NYCRR 217; (ii) the service provided is not a covered
50 benefit under the contract or agreement, including but not limited to, a
51 determination that such service is not medically necessary or is exper-
52 imental or investigational; (iii) the insured did not obtain a referral,
53 pre-certification or satisfy any other condition precedent to receive
54 covered benefits from the physician; (iv) the covered benefit exceeds
55 the benefit limits of the contract or agreement; (v) the person is not
56 eligible for coverage or is otherwise not compliant with the terms and
A. 8884 3
1 conditions of his or her contract; (vi) another insurer, corporation or
2 organization is liable for all or part of the claim; or (vii) the plan
3 has a reasonable suspicion of fraud or abuse. [In addition, nothing in
4 this section shall be deemed to require a health plan to pay or reim-
5 burse a claim, in full or in part, or dictate the amount of a claim to
6 be paid by a health plan to a physician.
7 (4)] (10) Every health plan shall publish on its provider website and
8 in its provider newsletter the name of the commercially available claims
9 editing software product that the health plan utilizes and any signif-
10 icant edits, as determined by the health plan, added to the claims soft-
11 ware product after the effective date of this section, which are made at
12 the request of the health plan. The health plan shall also provide such
13 information upon the written request of a physician who is a participat-
14 ing physician in the health plan's provider network.
15 (b) Overpayments to health care providers. (1) Other than recovery for
16 duplicate payments, a health plan shall provide thirty days written
17 notice to health care providers before engaging in additional overpay-
18 ment recovery efforts seeking recovery of the overpayment of claims to
19 such health care providers. Such notice shall state the patient name,
20 service date, payment amount, proposed adjustment, and a reasonably
21 specific explanation of the proposed adjustment.
22 (2) A health plan shall provide a health care provider with the oppor-
23 tunity to challenge an overpayment recovery, including the sharing of
24 claims information, and shall establish written policies and procedures
25 for health care providers to follow to challenge an overpayment recov-
26 ery. Such challenge shall set forth the specific grounds on which the
27 provider is challenging the overpayment recovery.
28 (3) A health plan shall not initiate overpayment recovery efforts more
29 than twenty-four months after the original payment was received by a
30 health care provider. However, no such time limit shall apply to over-
31 payment recovery efforts that are: (i) based on a reasonable belief of
32 fraud or other intentional misconduct, or abusive billing, (ii) required
33 by, or initiated at the request of, a self-insured plan, or (iii)
34 required or authorized by a state or federal government program or
35 coverage that is provided by this state or a municipality thereof to its
36 respective employees, retirees or members. Notwithstanding the aforemen-
37 tioned time limitations, in the event that a health care provider
38 asserts that a health plan has underpaid a claim or claims, the health
39 plan may defend or set off such assertion of underpayment based on over-
40 payments going back in time as far as the claimed underpayment. For
41 purposes of this paragraph, "abusive billing" shall be defined as a
42 billing practice which results in the submission of claims that are not
43 consistent with A PHYSICIAN'S sound fiscal, business, or medical prac-
44 tices and at such frequency and for such a period of time as to reflect
45 a consistent course of conduct. EVERY INSTANCE OF ALLEGED ABUSIVE BILL-
46 ING SHALL BE SUBSTANTIATED BY A REVIEW OF THE MEDICAL RECORD PERTAINING
47 TO EACH CLAIM FOR WHICH FINANCIAL RECOVERY IS SOUGHT. WHEN THERE IS A
48 DISPUTE BETWEEN AN INSURER AND PHYSICIAN OVER WHETHER OR NOT A CLAIM
49 CONSTITUTES ABUSIVE BILLING, IT SHALL BE REFERRED TO AND RESOLVED BY THE
50 INDEPENDENT DISPUTE RESOLUTION REVIEW BOARD AS SPECIFIED IN PARAGRAPH
51 NINE OF THIS SUBSECTION. NOTWITHSTANDING ANY LIMITATIONS WRITTEN INTO
52 EXISTING CONTRACTS BETWEEN AN INSURER AND A PHYSICIAN, PHYSICIANS MAY
53 OFFSET SUCH INSURER OVERPAYMENT CLAIMS WITH INSTANCES OF DOCUMENTED
54 UNDERPAYMENT DURING THE PERIOD IN QUESTION.
55 (4) For the purposes of this subsection the term "health care provid-
56 er" shall mean an entity licensed or certified pursuant to article twen-
A. 8884 4
1 ty-eight, thirty-six or forty of the public health law, a facility
2 licensed pursuant to article nineteen, thirty-one or thirty-two of the
3 mental hygiene law, or a health care professional licensed, registered
4 or certified pursuant to title eight of the education law.
5 (5) [Nothing in this section shall be deemed to limit a health plan's
6 right to pursue recovery of overpayments that occurred prior to the
7 effective date of this section where the health plan has provided the
8 health care provider with notice of such recovery efforts prior to the
9 effective date of this section.] ALL CLAIMS FOR ALLEGED OVERPAYMENTS
10 SHALL BE BASED ON AUDITS OF MEDICAL RECORDS FOR EACH CLAIM FOR WHICH AN
11 OVERPAYMENT IS ALLEGED AND MAY NOT BE EXTRAPOLATED FROM A SAMPLE OF
12 CLAIMS.
13 (6) INSURERS MAY NOT RECOUP CLAIMED OVERPAYMENTS BY OFFSETTING
14 REIMBURSEMENT OWED FOR SERVICES RENDERED TO OTHER PATIENTS EXCEPT WHERE
15 THERE IS CONSENT BY THE HEALTH CARE PROVIDER.
16 (7) WHERE THE INSURER HAS CONFIRMED THE ELIGIBILITY OF A PATIENT'S
17 COVERAGE PRIOR TO THE PROVISION OF SERVICES BY A PHYSICIAN WHO IN GOOD
18 FAITH RELIED UPON SUCH INSURER VERIFICATION, INSURER MAY NOT SUBSEQUENT-
19 LY SEEK FINANCIAL RECOVERY FROM A PHYSICIAN FOR SUCH RENDERED SERVICES
20 ON THE GROUNDS THAT THE PATIENT WAS NOT COVERED BY THE INSURER.
21 (8) INSURERS SHALL NOT REDUCE THE LEVEL OF CPT CODES FOR BILLED
22 COVERED SERVICES WITHOUT FIRST PERFORMING AN AUDIT REVIEW OF ALL THE
23 PERTINENT PATIENT MEDICAL RECORDS.
24 (9) THE SUPERINTENDENT SHALL ESTABLISH AN INDEPENDENT DISPUTE RESOL-
25 UTION REVIEW BOARD CONSISTING OF PHYSICIANS LICENSED TO PRACTICE MEDI-
26 CINE IN THE STATE OF NEW YORK WITHIN OR UNDER THE AUSPICES OF THE
27 DEPARTMENT AUTHORIZED TO HEAR AND RESOLVE INSURER-PHYSICIAN BILLING
28 DISPUTES BROUGHT BY EITHER THE INSURER OR THE PHYSICIAN. THE SUPERINTEN-
29 DENT SHALL ESTABLISH A CASE ADMINISTRATION FEE TO COVER THE COST
30 INCURRED BY THE DISPUTE REVIEW BOARD (INCLUDING EXPERT CPT CODING
31 CONSULTANTS) IN REVIEWING AND DECIDING A BILLING DISPUTE. THIS FEE IS TO
32 BE BORNE BY THE PARTY WHO LOSES THE DISPUTE DECISION.
33 S 3. This act shall take effect immediately and shall apply to all
34 contracts entered into, renewed (automatically or otherwise), modified
35 or amended on or after such date.
