S T A T E   O F   N E W   Y O R K
________________________________________________________________________

                                  5145

                       2013-2014 Regular Sessions

                          I N  A S S E M B L Y

                            February 20, 2013
                               ___________

Introduced  by  M.  of  A. GOTTFRIED, LAVINE, MAGNARELLI, GALEF, PAULIN,
  JACOBS, SCHIMEL, HIKIND, LIFTON, JAFFEE, ZEBROWSKI,  MONTESANO,  McDO-
  NOUGH,  SCARBOROUGH,  BROOK-KRASNY  --  Multi-Sponsored by -- M. of A.
  COLTON, GLICK, McDONALD, SWEENEY, THIELE -- read once and referred  to
  the Committee on Insurance

AN  ACT to amend the insurance law, in relation to insurer recovery from
  health care providers

  THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section  1.  Paragraph  3  of  subsection (b) of section 3224-b of the
insurance law, as amended by chapter 237 of the laws of 2009, is amended
and two new paragraphs 6 and 7 are added to read as follows:
  (3) A health plan shall not initiate overpayment recovery efforts more
than [twenty-four] TWELVE months after the original payment was received
by a health care provider. However, no such time limit  shall  apply  to
overpayment  recovery efforts that are: (i) based on a reasonable belief
of fraud or other intentional misconduct[,  or  abusive  billing],  (ii)
required  by,  or  initiated  at the request of, a self-insured plan, or
(iii) required or authorized by a state or federal government program or
coverage that is provided by this state or a municipality thereof to its
respective employees, retirees or members. Notwithstanding the aforemen-
tioned time limitations, in  the  event  that  a  health  care  provider
asserts  that  a health plan has underpaid a claim or claims, the health
plan may defend or set off such assertion of underpayment based on over-
payments going back in time as far as the claimed  underpayment.    [For
purposes  of  this  paragraph,  "abusive  billing" shall be defined as a
billing practice which results in the submission of claims that are  not
consistent with sound fiscal, business, or medical practices and at such
frequency  and  for  such  a  period  of time as to reflect a consistent
course of conduct.]

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD00944-01-3

              

A. 5145                             2

  (6) A HEALTH PLAN SHALL NOT DETERMINE AN  OVERPAYMENT  AMOUNT  THROUGH
THE  USE  OF  EXTRAPOLATION  EXCEPT  WITH THE CONSENT OF THE HEALTH CARE
PROVIDER, EXCEPT WHERE THERE IS A REASONABLE BELIEF OF FRAUD  OR  INTEN-
TIONAL MISCONDUCT.
  (7)  A  HEALTH  CARE  PLAN  MAY NOT THREATEN TO SANCTION A HEALTH CARE
PROVIDER INCLUDING A REPORT TO A RELEVANT DISCIPLINARY BODY AS A  RESULT
OF  A  HEALTH  CARE  PROVIDER  CHALLENGING AN ALLEGED OVERPAYMENT EXCEPT
WHERE THERE IS A REASONABLE BELIEF OF FRAUD OR INTENTIONAL MISCONDUCT. A
HEALTH CARE PLAN FOUND TO HAVE VIOLATED THIS PARAGRAPH SHALL BE  SUBJECT
TO A FINE OF FIFTY THOUSAND DOLLARS PER VIOLATION.
  S 2. This act shall take effect immediately.