senate Bill S3546

Relates to providing for the use of treatment guidelines in the no-fault system

download pdf

Sponsor

Bill Status


  • Introduced
  • In Committee
  • On Floor Calendar
    • Passed Senate
    • Passed Assembly
  • Delivered to Governor
  • Signed/Vetoed by Governor
view actions

actions

  • 05 / Feb / 2013
    • REFERRED TO INSURANCE
  • 08 / Jan / 2014
    • REFERRED TO INSURANCE

Summary

Relates to providing for the use of treatment guidelines in the no-fault system; prohibits insurers from paying any charge which exceeds the applicable fee schedule or which is not provided for under the fee schedule or compensable under Medicare.

do you support this bill?

Bill Details

Versions:
S3546
Legislative Cycle:
2013-2014
Current Committee:
Senate Insurance
Law Section:
Insurance Law
Laws Affected:
Amd ยงยง5108 & 5106, Ins L
Versions Introduced in 2011-2012 Legislative Cycle:
S6706

Sponsor Memo

BILL NUMBER:S3546

TITLE OF BILL: An act to amend the insurance law, in relation to
providing for the use of treatment guidelines under the comprehensive
motor vehicle reparations act

PURPOSE: To eliminate fraudulent and unnecessary medical treatment in
the no-fault system.

SUMMARY OF PROVISIONS: Section 1 of this bill would require the estab-
lishment of treatment guidelines for medical treatment provided under
the no-fault system.

Section 2 of this bill would provide an expedited process for the resol-
ution of disputes regarding deviations from the treatment guidelines.

Section 3 of the bill is the effective date.

JUSTIFICATION: On February 29, 2012, the Manhattan U.S. Attorney
announced the indictment of 36 people for participating in a $279
million no-fault fraud scheme involving fraudulent medical clinics
(medical mills) One of the reasons why medical mills proliferate in New
York is because New York's no-fault system makes it very easy to bill
insurance companies for fraudulent and unnecessary treatment. This bill
would remedy this situation by establishing guidelines for the treatment
of various injuries commonly sustained in automobile accidents.

Treatment guidelines have been adopted in New Jersey for its no-fault
system and in New York for the workers compensation system. Treatment
guidelines are a valuable tool in preventing the fraudulent overutiliza-
tion of unnecessary medical treatments Treatment guidelines are evidence
based standards of care and best practices for the medical treatment of
injuries which ensure that claimants receive the highest quality medical
treatment In the workers compensation context, the guidelines were
initially developed by the Governor's Workers Compensation Reform Task
Force and its advisory committee comprised of well credentialed medical
professionals and other interested parties. This bill would require
similar scientifically based guidelines to be developed for the treat-
ment of injuries commonly resulting from auto accidents. These guide-
lines would ensure that auto accident victims would receive the best
care for their injuries and, because the guidelines set forth clear
standards for treatment, they would significantly reduce fraud and abuse
in the no-fault system. Establishing treatment guidelines would go a
long way toward putting an end to medical mills in New York State.

New York's no fault system is plagued by fraud and abuse which is adding
significant costs to auto premiums in New York and a major contributing
factor making New Yorkers pay among the highest auto insurance premiums
in the nation. In fact, a recent Insurance Research Council study found
that in the New York City area, about one in every five no-fault auto
insurance claims closed in 2010 appear to have elements of fraud. In

addition, New York's no-fault claim costs have far outpaced that of
other no-fault states and the overall cost of medical care. From 2004
through the 2nd Quarter of 2010, the average PIP claim cost rose 60.4
percent in New York, nearly 42 points faster than the 18.6 percent
growth rate in the Consumer Price Index cost of medical goods and
services found in the region The cost of no-fault personal injury
protection (PIP) coverage has also soared New York's average no-fault
PIP claim cost $9,007 is the third highest in the nation as of 2nd quar-
ter 2010 Establishing treatment guidelines for the no-fault system would
assist in reducing fraud in the no-fault system and the costs associated
with fraud

LEGISLATIVE HISTORY: 5.6706 of 2011-12

FISCAL IMPLICATIONS: None.

EFFECTIVE DATE: Immediately and shall apply to all actions and
proceedings commenced on or after such date; and shall also apply to any
action or proceeding which was commenced prior to such effective date
where, as of such date, a trial of the issues has not yet commenced.

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

                                  3546

                       2013-2014 Regular Sessions

                            I N  S E N A T E

                            February 5, 2013
                               ___________

Introduced  by  Sen.  SEWARD -- read twice and ordered printed, and when
  printed to be committed to the Committee on Insurance

AN ACT to amend the insurance law, in relation to providing for the  use
  of  treatment guidelines under the comprehensive motor vehicle repara-
  tions act

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

  Section  1.    Section 5108 of the insurance law is amended to read as
follows:
  S 5108. Limit on charges by providers  of  health  services.  (a)  The
charges  for  services  specified  in paragraph one of subsection (a) of
section five thousand one hundred two of this article  and  any  further
health  service charges which are incurred as a result of the injury and
which are in excess of basic economic loss, shall not exceed the charges
permissible under the schedules prepared and established by the chairman
of the workers' compensation  board  for  industrial  accidents,  except
where  the  insurer  or arbitrator determines that unusual procedures or
unique circumstances justify the excess charge, AND SHALL BE SUBJECT  TO
THE  TREATMENT GUIDELINES ESTABLISHED PURSUANT TO SUBSECTION (D) OF THIS
SECTION.  AT NO TIME SHALL AN INSURER PAY ANY CHARGE  THAT  EXCEEDS  THE
CHARGES  PERMISSIBLE  UNDER THE SCHEDULE PREPARED AND ESTABLISHED BY THE
CHAIR OF THE WORKERS' COMPENSATION BOARD.
  (b) The superintendent, after consulting  with  the  chairman  of  the
workers'  compensation  board  and  the  commissioner  of  health, shall
promulgate rules  and  regulations  implementing  and  coordinating  the
provisions  of  this  article  and  the  workers'  compensation law with
respect to charges for the professional  health  services  specified  in
paragraph one of subsection (a) of section five thousand one hundred two
of  this  article, including the establishment of schedules for all such
services for which schedules have not been prepared and  established  by
the  chairman  of  the  workers'  compensation board, INCLUDING, BUT NOT

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD08136-01-3

S. 3546                             2

LIMITED TO, DURABLE MEDICAL EQUIPMENT OR SUPPLIES.    ADDITIONALLY,  THE
SUPERINTENDENT,  AFTER CONSULTATION WITH THE WORKERS' COMPENSATION BOARD
AND THE COMMISSIONER OF HEALTH, SHALL  PROMULGATE  TREATMENT  GUIDELINES
WITH RESPECT TO TREATING COVERED PERSONS.  CHARGES FOR SERVICES THAT ARE
NOT  SPECIFICALLY  SCHEDULED  BY  THE SUPERINTENDENT OF INSURANCE OR THE
CHAIRMAN OF THE WORKERS' COMPENSATION  BOARD,  OR  ARE  NOT  COMPENSABLE
CHARGES  UNDER MEDICARE ARE NOT COMPENSABLE HEALTH SERVICE CHARGES UNDER
SUBSECTION (A) OF SECTION FIVE THOUSAND ONE HUNDRED TWO OF THIS ARTICLE.
  (c) No provider of health  services  specified  in  paragraph  one  of
subsection  (a) of section five thousand one hundred two of this article
may demand or request any payment in addition to the charges  authorized
pursuant  to  this  section.  NO SUCH PROVIDER MAY BE REIMBURSED FOR ANY
SERVICES UNLESS THE  PROVIDER  COMPLIES  WITH  SUBSECTION  (D)  OF  THIS
SECTION.  Every  insurer  shall report to the commissioner of health any
patterns of overcharging, excessive treatment or other improper  actions
by a health provider within thirty days after such insurer has knowledge
of such pattern.
  (D) NOTWITHSTANDING ANY OTHER PROVISION OF STATUTE, RULE OR REGULATION
TO  THE CONTRARY, THE FOLLOWING SHALL APPLY FOR ALL INDIVIDUALS OR ENTI-
TIES THAT PROVIDE, TREAT, OR CHARGE FOR SERVICES SPECIFIED IN  PARAGRAPH
ONE  OF  SUBSECTION (A) OF SECTION FIVE THOUSAND ONE HUNDRED TWO OF THIS
ARTICLE:
  (1) THE TREATING PROVIDER SHALL FOLLOW THE TREATMENT GUIDELINES ESTAB-
LISHED BY THE SUPERINTENDENT;
  (2) DEVIATIONS FROM THE TREATMENT GUIDELINES MAY  BE  PERMITTED  UNDER
THE FOLLOWING CONDITIONS:
  (I)  PRIOR WRITTEN OR ELECTRONIC REQUEST IS GIVEN TO THE INSURER PRIOR
TO COMMENCING TREATMENT. THE REQUEST SHALL CONTAIN JUSTIFICATION FOR THE
DEVIATION FROM THE TREATMENT  GUIDELINES.  THE  BURDEN  OF  SHOWING  THE
NECESSITY  OF  THE  DEVIATION  REMAINS  SOLELY ON THE TREATING PROVIDER.
FAILURE TO PROVIDE THIS REQUEST SHALL RESULT IN A MAXIMUM  REIMBURSEMENT
OF FIFTY PERCENT OF THE TREATMENT GUIDELINES.
  (II)  THE INSURER SHALL NOT BE PRECLUDED FROM EVALUATING THE DEVIATION
FOR PAYMENT DURING THE PENDENCY OF THE  REVIEW,  AND  MAY  UTILIZE  PEER
REVIEW FOR EVALUATION OF THE DEVIATION.
  (III)  ANY  DISPUTES  SHALL BE RESOLVED THROUGH A PANEL OF EXPERTS WHO
HAVE BEEN TRAINED OR CERTIFIED IN THE TREATMENT GUIDELINES  PURSUANT  TO
SUBSECTION (E) OF SECTION FIVE THOUSAND ONE HUNDRED SIX OF THIS ARTICLE.
  (3)  AN INSURER MAY SCHEDULE AN INDEPENDENT MEDICAL EXAMINATION AT ANY
TIME DURING THE COURSE OF TREATMENT.
  (4) SERVICES OR SUPPLIES NOT COVERED BY THE  TREATMENT  GUIDELINES  OR
THE WORKERS' COMPENSATION FEE SCHEDULE SHALL NOT BE COMPENSABLE.
  S  2.  Section  5106  of  the insurance law is amended by adding a new
subsection (e) to read as follows:
  (E) EVERY INSURER SHALL PROVIDE THE TREATING PROVIDER WITH THE  OPTION
OF  SUBMITTING  A  DISPUTE  INVOLVING  A REQUEST FOR DEVIATIONS FROM THE
TREATMENT GUIDELINES UNDER SUBSECTION (D) OF SECTION FIVE  THOUSAND  ONE
HUNDRED  EIGHT  OF  THIS  ARTICLE  TO ARBITRATION PURSUANT TO SIMPLIFIED
PROCEDURES PROMULGATED OR APPROVED BY THE SUPERINTENDENT.  SUCH  SIMPLI-
FIED PROCEDURES SHALL INCLUDE ARBITRATION THROUGH A PANEL OF EXPERTS WHO
HAVE BEEN TRAINED OR CERTIFIED IN THE TREATMENT GUIDELINES.
  S  3.  This  act  shall take effect immediately and shall apply to all
actions and proceedings commenced on or after such date; and shall  also
apply  to  any  action  or  proceeding which was commenced prior to such
effective date where, as of such date, a trial of the issues has not yet
commenced.

Comments

Open Legislation comments facilitate discussion of New York State legislation. All comments are subject to moderation. Comments deemed off-topic, commercial, campaign-related, self-promotional; or that contain profanity or hate speech; or that link to sites outside of the nysenate.gov domain are not permitted, and will not be published. Comment moderation is generally performed Monday through Friday.

By contributing or voting you agree to the Terms of Participation and verify you are over 13.