S T A T E O F N E W Y O R K
________________________________________________________________________
4704
2011-2012 Regular Sessions
I N A S S E M B L Y
February 7, 2011
___________
Introduced by M. of A. MORELLE, SPANO, ROBINSON -- Multi-Sponsored by --
M. of A. GALEF, MAGEE, MAYERSOHN -- read once and referred to the
Committee on Insurance
AN ACT to amend the insurance law, in relation to unauthorized providers
of health services
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. The opening paragraph of section 5102 of the insurance law
is amended and a new subsection (n) is added to read as follows:
In this [chapter] ARTICLE:
(N) "PROVIDER OF HEALTH SERVICES" MEANS A PERSON OR ENTITY WHO RENDERS
HEALTH SERVICES.
S 2. Section 5109 of the insurance law, as added by chapter 423 of the
laws of 2005, is amended to read as follows:
S 5109. Unauthorized providers of health services. (a) [The super-
intendent, in consultation with the commissioner of health and the
commissioner of education, shall by regulation, promulgate standards and
procedures for investigating and suspending or removing the authori-
zation for providers of health services to demand or request payment for
health services as specified in paragraph one of subsection (a) of
section five thousand one hundred two of this article upon findings
reached after investigation pursuant to this section. Such regulations
shall ensure the same or greater due process provisions, including
notice and opportunity to be heard, as those afforded physicians inves-
tigated under article two of the workers' compensation law and shall
include provision for notice to all providers of health services of the
provisions of this section and regulations promulgated thereunder at
least ninety days in advance of the effective date of such regulations]
AS USED IN THIS SECTION, "HEALTH SERVICES" MEANS SERVICES, SUPPLIES,
THERAPIES OR OTHER TREATMENTS AS SPECIFIED IN SUBPARAGRAPH (I), (II) OR
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD07689-01-1
A. 4704 2
(IV) OF PARAGRAPH ONE OF SUBSECTION (A) OF SECTION FIVE THOUSAND ONE
HUNDRED TWO OF THIS ARTICLE.
(b) [The commissioner of health and the commissioner of education
shall provide a list of the names of all providers of health services
who the commissioner of health and the commissioner of education shall
deem, after reasonable investigation, not authorized to demand or
request any payment for medical services in connection with any claim
under this article because such] THE SUPERINTENDENT MAY PROHIBIT A
provider of health services FROM DEMANDING OR REQUESTING PAYMENT FOR
HEALTH SERVICES RENDERED UNDER THIS ARTICLE, FOR A PERIOD NOT EXCEEDING
THREE YEARS, IF THE SUPERINTENDENT DETERMINES, AFTER NOTICE AND HEARING,
THAT THE PROVIDER OF HEALTH SERVICES:
(1) has ADMITTED TO, OR been FOUND guilty of, professional [or other]
misconduct, AS DEFINED IN THE EDUCATION LAW, [or incompetency] in
connection with [medical] HEALTH services rendered under this article;
[or
(2) has exceeded the limits of his or her professional competence in
rendering medical care under this article or has knowingly made a false
statement or representation as to a material fact in any medical report
made in connection with any claim under this article; or
(3)] (2) solicited, or [has] employed another PERSON to solicit for
[himself or herself] THE PROVIDER OF HEALTH SERVICES or [for] another
PERSON OR ENTITY, professional treatment, examination or care of [an
injured] A person in connection with any claim under this article; [or
(4) has] (3) refused to appear before, or [to] answer ANY QUESTION
upon request of, the [commissioner of health, the] superintendent[,] or
any duly authorized officer of [the] THIS state, [any legal question,]
or REFUSED to produce any relevant information concerning [his or her]
THE conduct OF THE PROVIDER OF HEALTH SERVICES in connection with
[rendering medical] HEALTH services RENDERED under this article; [or
(5) has] (4) engaged in [patterns] A PATTERN of billing for:
(A) HEALTH services [which] ALLEGED TO HAVE BEEN RENDERED UNDER THIS
ARTICLE, WHEN THE HEALTH SERVICES were not [provided.] RENDERED; OR
(B) UNNECESSARY HEALTH SERVICES;
(5) UTILIZED UNLICENSED PERSONS TO RENDER HEALTH SERVICES UNDER THIS
ARTICLE, WHEN ONLY A PERSON LICENSED IN THIS STATE MAY RENDER THE HEALTH
SERVICES;
(6) UTILIZED LICENSED PERSONS TO RENDER HEALTH SERVICES, WHEN RENDER-
ING THE HEALTH SERVICES IS BEYOND THE AUTHORIZED SCOPE OF THE PERSON'S
LICENSE;
(7) CEDED OWNERSHIP, OPERATION OR CONTROL OF A BUSINESS ENTITY AUTHOR-
IZED TO PROVIDE PROFESSIONAL HEALTH SERVICES IN THIS STATE, INCLUDING
BUT NOT LIMITED TO A PROFESSIONAL SERVICE CORPORATION, PROFESSIONAL
LIMITED LIABILITY COMPANY OR REGISTERED LIMITED LIABILITY PARTNERSHIP,
TO A PERSON NOT LICENSED TO RENDER THE HEALTH SERVICES FOR WHICH THE
ENTITY IS LEGALLY AUTHORIZED TO PROVIDE, EXCEPT WHERE THE UNLICENSED
PERSON'S OWNERSHIP, OPERATION OR CONTROL IS OTHERWISE PERMITTED BY LAW;
(8) COMMITTED A FRAUDULENT INSURANCE ACT AS DEFINED IN SECTION 176.05
OF THE PENAL LAW;
(9) HAS BEEN CONVICTED OF A CRIME INVOLVING FRAUDULENT OR DISHONEST
PRACTICES; OR
(10) VIOLATED ANY PROVISION OF THIS ARTICLE OR REGULATIONS PROMULGATED
THEREUNDER.
(c) [Providers] A PROVIDER of health services shall [refrain from
subsequently treating for remuneration, as a private patient, any person
seeking medical treatment] NOT DEMAND OR REQUEST PAYMENT FOR ANY HEALTH
A. 4704 3
SERVICES under this article [if such provider pursuant to this section
has been prohibited from demanding or requesting any payment for medical
services under this article. An injured claimant so treated or examined
may raise this as] THAT ARE RENDERED DURING THE TERM OF THE PROHIBITION
ORDERED BY THE SUPERINTENDENT PURSUANT TO SUBSECTION (B) OF THIS
SECTION. THE PROHIBITION ORDERED BY THE SUPERINTENDENT MAY BE a defense
in any action by [such] THE provider OF HEALTH SERVICES for payment for
[treatment rendered at any time after such provider has been prohibited
from demanding or requesting payment for medical services in connection
with any claim under this article] SUCH HEALTH SERVICES.
(d) The [commissioner of health and the commissioner of education]
SUPERINTENDENT shall maintain [and regularly update] a database contain-
ing a list of providers of health services prohibited by this section
from demanding or requesting any payment for health services [connected
to a claim] RENDERED under this article and shall make [such] THE infor-
mation available to the public [by means of a website and by a toll free
number].
(E) THE SUPERINTENDENT MAY LEVY A CIVIL PENALTY NOT EXCEEDING FIFTY
THOUSAND DOLLARS ON ANY PROVIDER OF HEALTH SERVICES THAT THE SUPERINTEN-
DENT PROHIBITS FROM DEMANDING OR REQUESTING PAYMENT FOR HEALTH SERVICES
PURSUANT TO SUBSECTION (B) OF THIS SECTION. ANY CIVIL PENALTY IMPOSED
FOR A FRAUDULENT INSURANCE ACT, AS DEFINED IN SECTION 176.05 OF THE
PENAL LAW, SHALL BE LEVIED PURSUANT TO ARTICLE FOUR OF THIS CHAPTER.
[(e)] (F) Nothing in this section shall be construed as limiting in
any respect the powers and duties of the commissioner of health, commis-
sioner of education or the superintendent to investigate instances of
misconduct by a [health care] provider [and, after a hearing and upon
written notice to the provider, to temporarily prohibit a provider of
health services under such investigation from demanding or requesting
any payment for medical services under this article for up to ninety
days from the date of such notice] OF HEALTH SERVICES AND TAKE APPROPRI-
ATE ACTION PURSUANT TO ANY OTHER PROVISION OF LAW. A DETERMINATION OF
THE SUPERINTENDENT PURSUANT TO SUBSECTION (B) OF THIS SECTION SHALL NOT
BE BINDING UPON THE COMMISSIONER OF HEALTH OR THE COMMISSIONER OF EDUCA-
TION IN A PROFESSIONAL DISCIPLINE PROCEEDING RELATING TO THE SAME
CONDUCT.
S 3. This act shall take effect immediately.