senate Bill S160

2011-2012 Legislative Session

Establishes procedures for the collection of overpayments from health care providers

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Archive: Last Bill Status - In Committee


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

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Assembly Actions - Lowercase
Senate Actions - UPPERCASE
Jan 04, 2012 referred to insurance
Jan 05, 2011 referred to insurance

S160 - Bill Details

Current Committee:
Law Section:
Insurance Law
Laws Affected:
Amd §§3224-a, 4803 & 3217-b, Ins L; amd §§4406-c & 4406-d, Pub Health L
Versions Introduced in 2009-2010 Legislative Session:
S311

S160 - Bill Texts

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Establishes procedures for the collection of overpayments from health care providers; requires insurers to notify health care professionals regarding billing codes; and requires certain contracts entered into with health care providers to include certain information.

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BILL NUMBER:S160

TITLE OF BILL:
An act
to amend the insurance law and the public health law, in relation to
establishing procedures for the collection of overpayments from health
care providers based upon eligibility of the insured; and requiring
insurers to notify health care professionals by written and electronic
formats regarding particular billing codes; and requiring contracts
entered into with a health care provider to include certain information

PURPOSE:
Would assure that Physicians and other health care providers are given
adequate information when health plans seek refunds for previous
payments, and would assure that physicians are given information up
front about those items which might subject them to a health plan
audit in the future.

SUMMARY OF PROVISIONS:
The legislation would amend Section 3224-a of the Insurance Law to
establish procedures for the collection of overpayments based upon
eligibility of the insurer, and when the plan believes they overpaid
the provider.

1. For refund demands based on eligibility, the legislation would
require health insurance companies and HMOs to give specific
information to health care providers including the reason for the
refund demand, as well as any information the plan may have regarding
another responsible Payor. The legislation would grant a health care
provider an additional period of time to submit the claim to the
proper insurer.

2. For refund demands based upon coding disputes, the legislation
would require health plans to provide specific information to
providers about each claim for which a refund is sought to permit
providers the opportunity to adequately defend themselves. It would
prohibit the collection of overpayment demands unless and until a
meaningful opportunity to challenge the refund demand has been given.
The legislation would also prohibit extrapolation to determine
overpayments except where the provider consents to use extrapolation
and several other steps are taken to assure proper notice to the
provider, including disclosure of the extrapolation methodology.

IN ADDITION THE AMENDMENTS TO THIS SECTION WOULD:

Prohibit the collection of overpayments where utilization review has
already been made, except when the reason for the refund demand is the
ineligibility of the insured.

Prohibit the collection of overpayments by offsetting the future
payments unless the provider consents.

Permit health care providers to pay back overpayments in installments.

The legislation would also amend PHL Section 4406-d and the Insurance
Law Section Section 4603 to assure
that health plans, on a periodic basis, notify


providers regarding the inappropriate use of particular billing codes
that may subject a provider to an audit.

The legislation would also amend PHL Section 4406-d and Insurance Law
Section 4803 to assure the Health Department and Insurance Department
are apprised of any comparative profiling information that health
plans are sending to physicians.

The legislation would amend PHL Section 4406-c and Insurance Law
Section 3217-b to add to the list of those items that health plans
are required to divulge to contracting physicians:

That the health plan will notify the health care provider of specific
changes to the fee schedule or changes in the payment methodology as
soon as reasonably practicable;

That the provider can obtain information regarding specific fees by
submitting a request in writing or by electronic means;

That the provider can obtain the most recent information maintained by
the health plan regarding enrollment information.

JUSTIFICATION:
Many health care providers across New York State have been sent
demands by health insurance companies for refunds of claims
previously paid long after the time that such payment was made. These
refund demands have at times totaled tens of thousands or even
hundreds of thousands of dollars. To make matters worse, physicians
frequently are given little information from health plans regarding
why these refunds have been sought, making it difficult for the
physician to even have a meaningful opportunity to challenge the
refund demands. Moreover, because the health care provider will
likely continue providing care to, the health plan's enrollees, a
health plan will often seek to collect the alleged overpayments by
offsetting future payments owed by the health plan for health care
services rendered to other health plan enrollees, a situation that
greatly limits the ability of health care providers to challenge
these refund demands when appropriate.

This legislation would set forth the steps that a health plan or
insurer must take in order to collect a refund when a health plan
makes a determination post-payment that a patient was not insured at
the time of service, that the insurer was not the primary payor, or
that the insurer overpaid the health care provider. To wit because of
post-payment eligibility determinations, this legislation would
require the health plan seeking the refund to state in the notice to
the health care provider the company they believe is the legally
responsible payor, or state that they are not aware of another
legally responsible payor. This information is often never provided.
To address the current problem that a
health care provider may be unfairly time-barred, following a refund
demand, from submitting the claim to the appropriate payer, the
legislation would expressly permit a health care provider a window of
opportunity to seek payment from the health insurance company legally
responsible for making payment even though such health care provider
would otherwise be time-barred.


With regard to past-payment coding disputes, this legislation would
require health plans to specify in writing to the health care
provider a detailed finding for each and every claim for which the
health plan believes an overpayment was made. This would permit the
health care provider an opportunity to review their own records to
defend to the health plan why they believe the level of service
provided to the patient noted on the claim was appropriate. Moreover,
the legislation would prohibit, in most instances, the practice of
some health insurers which review a small number of claims and
extrapolate the findings over all claims submitted by such health
care provider to arrive at an often gargantuan overpayment demand
amount. Recognizing there may be instances when a health care
provider may prefer to use this sampling technique to determine a
total overpayment instead of agreeing to review of all claims they
have submitted, this legislation would permit the use of this
sampling and extrapolation methodology where the health care provider
consents.

This legislation would also prohibit health plans from collecting the
overpayment refund demanded unless the health care provider has been
given a meaningful opportunity to challenge the determination. In
those situations where a refund has been determined to be
appropriate, the bill would permit the overpayments to be paid back
in installments. An offset of future payments would be appropriate
where the health care provider consents.

Moreover, this legislation would enact proactive measures to assure
that health care providers are given appropriate notice regarding
issues that could subject a health care provider to an audit in the
future. For example, the legislation would require health plans to be
proactive in identifying billing practices that may cause health care
providers to be audited and subject to overpayment demands in the
future. The legislation would also assure that health care providers
are able to access the most up-to-date information maintained by the
health plan regarding the eligibility of a particular patient to have
their health care covered by that particular health plan. The
legislation would also assure that physicians will be advised as soon
as possible regarding changes to how the health plan will pay for
particular services rendered to the plan enrollees, so as to assure
that health care providers are in the health plan. To assure
compliance, the legislation would also, for the first time, establish
monetary penalties for health plans who fail to provide information
to their contracting health care providers as set forth by law.

This legislation would strike an appropriate balance between
permitting insurers the opportunity to review claims to protect
against health care fraud, while at the same time giving physicians
and other providers a meaningful opportunity to challenge efforts by
health plans to collect refund demands that in some cases may be
inappropriately sought.

LEGISLATIVE HISTORY:
S.7285 of 2004; Advanced to Third Reading
S.2377 of 2005; Referred to Senate Insurance Committee
S.32 of 2007-2006: Referred to Insurance
S.311 of 2009-2010; Referred to Insurance


FISCAL IMPLICATIONS: None.

EFFECTIVE DATE:
60 days after becoming a law.

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

                                   160

                       2011-2012 Regular Sessions

                            I N  S E N A T E

                               (PREFILED)

                             January 5, 2011
                               ___________

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

AN ACT to amend the insurance law and the public health law, in relation
  to establishing procedures for the  collection  of  overpayments  from
  health  care  providers  based  upon  eligibility  of the insured; and
  requiring insurers to notify health care professionals by written  and
  electronic  formats  regarding particular billing codes; and requiring
  contracts entered into with a health care provider to include  certain
  information

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

  Section 1. Section 3224-a of the insurance law is amended by adding  a
new subsection (b-1) to read as follows:
  (B-1)  WHERE  AN INSURER OR ORGANIZATION OR CORPORATION SEEKS A REFUND
FROM A HEALTH CARE PROVIDER OF A PAYMENT PREVIOUSLY MADE FOR HEALTH CARE
SERVICES:
  (1) IN A CASE WHERE AN INSURER OR ORGANIZATION OR CORPORATION IS SEEK-
ING A REFUND FOR PAYMENT PREVIOUSLY MADE BASED UPON A GOOD FAITH  BELIEF
REGARDING  THE ELIGIBILITY OF A PERSON FOR COVERAGE, OR THE LIABILITY OF
ANOTHER INSURER OR CORPORATION OR ORGANIZATION FOR ALL OR  PART  OF  THE
CLAIM, THE INSURER OR ORGANIZATION OR CORPORATION MUST NOTIFY THE HEALTH
CARE  PROVIDER  IN  WRITING  THE  AMOUNT OF THE REFUND BEING SOUGHT, THE
SPECIFIC REASONS WHY THE REFUND IS BEING SOUGHT, AND ANY INFORMATION  IT
MAY  HAVE  REGARDING ANOTHER INSURER, ORGANIZATION, CORPORATION OR OTHER
ENTITY THAT MAY BE LEGALLY OBLIGATED TO MAKE PAYMENT.  IF  THE  INSURER,
ORGANIZATION  OR  CORPORATION  SEEKING  THE REFUND DOES NOT MAINTAIN ANY
SUCH INFORMATION, IT SHALL SO STATE ON THE NOTICE  TO  THE  HEALTH  CARE
PROVIDER.  NOTICE OF SUCH REFUND DEMAND SHALL BE MADE AS SOON AS REASON-
ABLY PRACTICABLE AFTER RECEIPT OF INFORMATION THAT SUCH INSURER,  ORGAN-
IZATION OR CORPORATION WAS NOT RESPONSIBLE FOR PAYMENT. FAILURE TO IDEN-

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD01365-01-1

S. 160                              2

TIFY SUCH OTHER RESPONSIBLE PAYOR WHERE SUCH INFORMATION IS KNOWN TO THE
INSURER, OR ORGANIZATION OR CORPORATION, OR FAILURE TO TIMELY NOTIFY THE
HEALTH  CARE  PROVIDER  ONCE SUCH INFORMATION IS RECEIVED REGARDING THAT
SUCH  INSURER,  ORGANIZATION  OR  CORPORATION  WAS  NOT  RESPONSIBLE FOR
PAYMENT, SHALL  BAR  SUCH  INSURER,  ORGANIZATION  OR  CORPORATION  FROM
ATTEMPTING TO OBTAIN THE REFUND OF THE PREVIOUS PAYMENT. THE HEALTH CARE
PROVIDER  FROM  WHOM  THE  REFUND IS SOUGHT MAY SUBMIT SUCH CLAIM TO THE
LEGALLY RESPONSIBLE INSURER, CORPORATION OR  ORGANIZATION  FOR  PAYMENT.
FOR  THE  PURPOSES  OF  COMPLYING  WITH ANY TIME LIMITATION THE INSURER,
ORGANIZATION OR CORPORATION LEGALLY RESPONSIBLE  FOR  PAYMENT  MAY  HAVE
REGARDING  THE  SUBMISSION  OF  CLAIMS, THE DATE OF NOTICE OF THE REFUND
DEMAND FROM THE INSURER, ORGANIZATION OR CORPORATION SEEKING THE  REFUND
SHALL BE DEEMED TO BE THE DATE OF THE RENDERING OF HEALTH CARE SERVICES.
SUCH  TIME LIMITATION OF THE LEGALLY RESPONSIBLE INSURER, CORPORATION OR
ORGANIZATION SHALL BE EXCUSED WHERE THE IDENTITY OF SUCH INSURER, CORPO-
RATION OR ORGANIZATION CANNOT REASONABLY BE IDENTIFIED WITHIN  THE  TIME
LIMITATION.  ALL UTILIZATION REVIEW, AS DEFINED BY ARTICLE FORTY-NINE OF
THIS CHAPTER AND ARTICLE FORTY-NINE OF THE PUBLIC HEALTH LAW,  PERFORMED
BY  THE INSURER, ORGANIZATION OR CORPORATION SEEKING THE REFUND SHALL BE
BINDING ON THE LEGALLY RESPONSIBLE INSURER, ORGANIZATION OR  CORPORATION
TO  WHOM  THE  HEALTH  CARE PROVIDER SUBSEQUENTLY SUBMITS THE CLAIM. THE
CLAIM SHALL NOT BE DENIED BY THE LEGALLY RESPONSIBLE INSURER,  ORGANIZA-
TION  OR  CORPORATION  ON  THE BASIS OF LACK OF AUTHORIZATION TO PROVIDE
SUCH HEALTH CARE SERVICES.
  (2) IN A CASE WHERE THE INSURER  OR  ORGANIZATION  OR  CORPORATION  IS
SEEKING  THE  REFUND  BASED UPON A DETERMINATION REGARDING THE AMOUNT OF
THE CLAIM PAID, SUCH INSURER MAY NOT ATTEMPT TO  COLLECT  SUCH  PREVIOUS
PAYMENT UNLESS THE FOLLOWING CAN BE DEMONSTRATED:
  (I) THE INSURER, ORGANIZATION OR CORPORATION HAS IDENTIFIED IN WRITING
THE  FINDING  OF  EACH  AND  EVERY CLAIM REVIEWED SUFFICIENT TO GIVE THE
HEALTH CARE  PROVIDER  REASONABLY  SPECIFIC  NOTICE  WHY  SUCH  PREVIOUS
PAYMENT WAS ALLEGEDLY INAPPROPRIATELY MADE;
  (II)  THE  INSURER, ORGANIZATION OR CORPORATION PROVIDES TO THE HEALTH
CARE PROVIDER A FULL AND MEANINGFUL OPPORTUNITY TO CHALLENGE  THE  FIND-
INGS ON THE CLAIMS REVIEWED PRIOR TO THE COMMENCEMENT OF ANY ADVERSARIAL
PROCEEDING TO COLLECT ANY SUCH PREVIOUS PAYMENT ALLEGEDLY INAPPROPRIATE-
LY MADE; AND
  (III)  SUCH  INSURER,  ORGANIZATION  OR CORPORATION HAS DETERMINED AND
NOTIFIED THE HEALTH CARE PROVIDER IN WRITING IF THERE HAVE  BEEN  UNDER-
PAYMENTS  TO SUCH HEALTH CARE PROVIDER AND THE FULL AMOUNT OF THE UNDER-
PAYMENTS HAVE BEEN SUBTRACTED FROM THE TOTAL AMOUNT OF PREVIOUS PAYMENTS
ALLEGEDLY INAPPROPRIATELY MADE.
  (3) IN NO EVENT MAY AN INSURER, ORGANIZATION OR  CORPORATION,  WITHOUT
THE  CONSENT OF THE HEALTH CARE PROVIDER FROM WHOM THE REFUND IS SOUGHT,
USE EXTRAPOLATION TO DETERMINE  THE  TOTAL  OF  SUCH  PREVIOUS  PAYMENTS
ALLEGEDLY  INAPPROPRIATELY  MADE.  SUCH  CONSENT  MAY NOT BE OBTAINED BY
INCLUSION IN THE GENERAL CONTRACT OF THE HEALTH CARE PROVIDER  WITH  THE
INSURER, ORGANIZATION OR CORPORATION. IF EXTRAPOLATION IS USED TO DETER-
MINE  THE TOTAL AMOUNT THE INSURER, ORGANIZATION OR CORPORATION MUST, IN
ADDITION  TO  MEETING  THE  REQUIREMENTS  OF  PARAGRAPH  TWO   OF   THIS
SUBSECTION:
  (I)  PROVIDE INFORMATION TO THE HEALTH CARE PROVIDER HOW THE SAMPLE OF
CLAIMS WAS SELECTED UPON WHICH THE EXTRAPOLATED TOTAL WAS DETERMINED, AS
WELL AS THE ERROR RATE;

S. 160                              3

  (II) DEMONSTRATE THAT THE SAMPLE OF CLAIMS REVIEWED WAS SUFFICIENT  IN
SIZE TO PERMIT A GENERALIZATION FOR ALL CLAIMS SUBMITTED DURING THE TIME
PERIOD UNDER REVIEW;
  (III)  IDENTIFY  THE FINDINGS OF EACH AND EVERY CLAIM REVIEWED IN SUCH
SUFFICIENT DETAIL AS TO APPRISE THE HEALTH  CARE  PROVIDER  WHY  IT  WAS
DETERMINED THAT THE PREVIOUS PAYMENT WAS ALLEGEDLY INAPPROPRIATELY MADE;
  (IV)  ASSURE THAT THE FINDINGS OF THE CLAIMS REVIEWED ARE NOT EXTRAPO-
LATED TO CLAIMS THAT WERE SUBMITTED OUTSIDE OF THE PERIOD OF  TIME  THAT
CLAIMS WERE REVIEWED;
  (V) PROVIDE TO THE HEALTH CARE PROVIDER A FULL AND MEANINGFUL OPPORTU-
NITY  TO  CHALLENGE  THE FINDINGS ON THE CLAIMS REVIEWED, AS WELL AS THE
MANNER BY WHICH THE TOTAL AMOUNT OF PREVIOUS PAYMENTS ALLEGEDLY INAPPRO-
PRIATELY MADE WAS DETERMINED, PRIOR TO THE COMMENCEMENT  OF  ANY  ADVER-
SARIAL  PROCEEDING  TO COLLECT ANY SUCH INAPPROPRIATE PREVIOUS PAYMENTS;
AND
  (VI) DETERMINED IF THERE HAVE BEEN UNDERPAYMENTS TO SUCH  HEALTH  CARE
PROVIDER  AND  THOSE AMOUNTS HAVE BEEN USED TO OFFSET ANY RESPONSIBILITY
OF THE HEALTH CARE PROVIDER TO REPAY  THE  PREVIOUS  PAYMENTS  ALLEGEDLY
INAPPROPRIATELY MADE.
  (4)  IN  NO  EVENT MAY A REFUND FOR A PREVIOUS PAYMENT BE SOUGHT WHERE
UTILIZATION REVIEW PURSUANT TO ARTICLE FORTY-NINE  OF  THIS  CHAPTER  OR
ARTICLE  FORTY-NINE OF THE PUBLIC HEALTH LAW HAVE BEEN PERFORMED, EXCEPT
AS PROVIDED IN PARAGRAPH ONE OF THIS SUBSECTION.
  (5) IN NO EVENT MAY A REFUND FOR A PREVIOUS PAYMENT BE  SOUGHT  EXCEPT
AS OTHERWISE PROVIDED BY THIS SUBSECTION.
  (6)  IN  NO EVENT MAY AN INSURER, ORGANIZATION OR CORPORATION, WITHOUT
THE CONSENT OF THE HEALTH CARE PROVIDER, ATTEMPT TO OBTAIN SUCH PREVIOUS
PAYMENTS DETERMINED TO HAVE BEEN INAPPROPRIATELY MADE, AS SET  FORTH  IN
THIS  SUBSECTION,  BY OFFSETTING FUTURE PAYMENTS DUE TO SUCH HEALTH CARE
PROVIDER. SUCH CONSENT MAY NOT BE OBTAINED BY INCLUSION IN  THE  GENERAL
CONTRACT  BETWEEN THE HEALTH CARE PROVIDER AND THE INSURER, ORGANIZATION
OR CORPORATION.
  (7) THE HEALTH CARE PROVIDER SHALL BE GIVEN A PERIOD  OF  TIME  OF  NO
LESS  THAN SIX MONTHS TO REFUND PREVIOUS PAYMENTS THAT HAVE BEEN, AS SET
FORTH IN THIS SUBSECTION, DETERMINED TO BE INAPPROPRIATELY MADE.
  S 2. Subsection (d) of section 4803 of the insurance law, as added  by
chapter 705 of the laws of 1996, is amended to read as follows:
  (d)  An insurer shall develop and implement policies and procedures to
ensure that health care providers participating in the [the]  in-network
benefits  portion of an insurer's network for a managed care product are
regularly informed of information maintained by the insurer to  evaluate
the performance or practice of the health care professional. The insurer
shall consult with health care professionals in developing methodologies
to  collect  and analyze provider profiling data. Insurers shall provide
any such information and profiling data and  analysis  to  these  health
care professionals. Such information, data or analysis shall be provided
on a periodic basis appropriate to the nature and amount of data and the
volume and scope of services provided. SUCH INFORMATION, DATA AND ANALY-
SIS SHALL BE PROVIDED TO THE SUPERINTENDENT AT THE SAME TIME SUCH INFOR-
MATION,  DATA AND ANALYSIS IS PROVIDED TO HEALTH CARE PROFESSIONALS. Any
profiling data used to evaluate the performance or practice  of  such  a
health  care  professional shall be measured against stated criteria and
an appropriate group of health care professionals using  similar  treat-
ment  modalities serving a comparable patient population. Upon presenta-
tion of such information or data, each  such  health  care  professional
shall  be  given  the  opportunity  to  discuss the unique nature of the

S. 160                              4

health care professional's patient population which may have  a  bearing
on the professional's profile and to work cooperatively with the insurer
to  improve  performance.  AN INSURER SHALL, ON A PERIODIC BASIS, NOTIFY
HEALTH  CARE  PROFESSIONALS  BY WRITTEN AND ELECTRONIC FORMATS REGARDING
PARTICULAR BILLING CODES USED BY HEALTH CARE PROFESSIONALS WHICH MAY  BE
OVERUTILIZED  OR  INAPPROPRIATELY UTILIZED. SUCH NOTIFICATION SHALL BE A
CONDITION PRECEDENT  TO  TAKE  ANY  ACTION  TO  RECOUP  PREVIOUSLY  PAID
PAYMENTS  UNDER SECTION THREE THOUSAND TWO HUNDRED TWENTY-FOUR-A OF THIS
CHAPTER.
  S 3. Subdivision 4 of section 4406-d of  the  public  health  law,  as
added by chapter 705 of the laws of 1996, is amended to read as follows:
  4.  A health care plan shall develop and implement policies and proce-
dures to ensure that health care professionals are regularly informed of
information maintained by the health care plan to evaluate the  perform-
ance  or  practice of the health care professional. The health care plan
shall consult with health care professionals in developing methodologies
to collect and analyze health care professional profiling  data.  Health
care  plans  shall  provide  any such information and profiling data and
analysis to health care professionals. Such information, data or  analy-
sis  shall be provided on a periodic basis appropriate to the nature and
amount of data and the volume and scope  of  services  provided.    SUCH
INFORMATION,  DATA AND ANALYSIS SHALL ALSO BE PROVIDED TO THE DEPARTMENT
AT THE SAME TIME THE INFORMATION,  DATA  AND  ANALYSIS  IS  PROVIDED  TO
HEALTH  CARE  PROFESSIONALS.  Any  profiling  data  used to evaluate the
performance or practice of a health care professional shall be  measured
against  stated criteria and an appropriate group of health care profes-
sionals using similar treatment modalities serving a comparable  patient
population.  Upon  presentation of such information or data, each health
care professional shall be given the opportunity to discuss  the  unique
nature  of  the  health care professional's patient population which may
have a bearing on the health care professional's  profile  and  to  work
cooperatively  with  the  health  care  plan to improve performance.   A
HEALTH CARE PLAN SHALL, ON A PERIODIC BASIS, NOTIFY HEALTH CARE  PROFES-
SIONALS  BY  WRITTEN AND ELECTRONIC FORMATS REGARDING PARTICULAR BILLING
CODES USED BY HEALTH CARE PROFESSIONALS WHICH  MAY  BE  OVERUTILIZED  OR
INAPPROPRIATELY  UTILIZED. SUCH NOTIFICATION SHALL BE A CONDITION PRECE-
DENT TO TAKING ANY ACTION TO RECOUP PAYMENTS PREVIOUSLY PAID AS PROVIDED
UNDER SECTION THREE THOUSAND TWO HUNDRED TWENTY-FOUR-A OF THE  INSURANCE
LAW.
  S  4.  Subsection (e) of section 3217-b of the insurance law, as added
by chapter 586 of the laws of 1998, is amended to read as follows:
  (e) Contracts entered into  between  an  insurer  and  a  health  care
provider shall include terms which prescribe:
  (1) the method by which payments to a provider, including any prospec-
tive or retrospective adjustments thereto, shall be calculated;
  (2) the time periods within which such calculations will be completed,
the  dates  upon which any such payments and adjustments shall be deter-
mined to be due, and the dates upon which any such payments and  adjust-
ments will be made;
  (3)  a description of the records or information relied upon to calcu-
late any such payments and adjustments, and a  description  of  how  the
provider can access a summary of such calculations and adjustments;
  (4) the process to be employed to resolve disputed incorrect or incom-
plete records or information and to adjust any such payments and adjust-
ments  which  have  been  calculated by relying on any such incorrect or
incomplete records or information so disputed; provided,  however,  that

S. 160                              5

nothing herein shall be deemed to authorize or require the disclosure of
personally  identifiable  patient  information or information related to
other individual health care providers or the  plan's  proprietary  data
collection  systems, software or quality assurance or utilization review
methodologies; [and]
  (5) the right of either party to the contract to seek resolution of  a
dispute  arising pursuant to the payment terms of such contracts through
a proceeding under article seventy-five of the civil  practice  law  and
rules;
  (6)  THAT  THE INSURER WILL NOTIFY THE PROVIDER, ELECTRONICALLY AND IN
WRITING, AS SOON AS REASONABLY PRACTICABLE, OF SPECIFIC CHANGES  TO  THE
APPLICABLE  PAYMENT  SCHEDULE  AND/OR  SPECIFIC CHANGES TO THE MANNER BY
WHICH PAYMENTS WILL BE CALCULATED;
  (7) THAT A PROVIDER CAN OBTAIN SPECIFIC INFORMATION FROM  THE  INSURER
REGARDING  THE  PAYMENT  FOR  A  PARTICULAR  SERVICE OR SERVICES, OR THE
MANNER BY WHICH PAYMENTS WILL BE CALCULATED, BY SUBMITTING A REQUEST  IN
WRITING OR BY SUBMITTING A REQUEST VIA ELECTRONIC MEANS; AND
  (8) THAT THE PROVIDER WILL BE ABLE TO OBTAIN THE MOST CURRENT INFORMA-
TION MAINTAINED BY THE INSURER REGARDING THE ELIGIBILITY OF A PARTICULAR
PATIENT  TO  RECEIVE COVERED SERVICES. A VIOLATION OR FAILURE TO PERFORM
ANY OBLIGATION IMPOSED UNDER THIS SECTION SHALL RESULT IN A CIVIL PENAL-
TY NOT TO EXCEED  ONE  THOUSAND  DOLLARS  FOR  EACH  SUCH  VIOLATION  OR
FAILURE.
  S  5.  Subdivision  5-a of section 4406-c of the public health law, as
added by chapter 586 of the laws of 1998, is amended to read as follows:
  5-a. Contracts entered into between a plan and a health care  provider
shall include terms which prescribe:
  (a) the method by which payments to a provider, including any prospec-
tive or retrospective adjustments thereto, shall be calculated;
  (b) the time periods within which such calculations will be completed,
the  dates  upon which any such payments and adjustments shall be deter-
mined to be due, and the dates upon which any such payments and  adjust-
ments will be made;
  (c)  a description of the records or information relied upon to calcu-
late any such payments and adjustments, and a  description  of  how  the
provider can access a summary of such calculations and adjustments;
  (d)  the  process to be employed to [resolved] RESOLVE disputed incor-
rect or incomplete  records  or  information  and  to  adjust  any  such
payments  and  adjustments  which have been calculated by relying on any
such incorrect or incomplete records or information and  to  adjust  any
such  payments  and adjustments which have been calculated by relying on
any such incorrect or incomplete records  or  information  so  disputed;
provided,  however,  that nothing herein shall be deemed to authorize or
require the disclosure of personally identifiable patient information or
information related to other individual health  care  providers  or  the
plan's  proprietary  data collection systems, software or quality assur-
ance or utilization review methodologies; [and]
  (e) the right of either party to the contract to seek resolution of  a
dispute arising pursuant to the payment terms of such contract through a
proceeding  under  article  seventy-five  of  the civil practice law and
rules;
  (F) THAT THE PLAN WILL NOTIFY  THE  PROVIDER,  ELECTRONICALLY  AND  IN
WRITING,  AS  SOON AS REASONABLY PRACTICABLE, OF SPECIFIC CHANGES TO THE
APPLICABLE PAYMENT SCHEDULE AND/OR SPECIFIC CHANGES  TO  THE  MANNER  BY
WHICH PAYMENTS WILL BE CALCULATED;

S. 160                              6

  (G)  THAT  THE  PROVIDER CAN OBTAIN SPECIFIC INFORMATION FROM THE PLAN
REGARDING THE PAYMENT FOR A  PARTICULAR  SERVICE  OR  SERVICES,  OR  THE
MANNER  BY WHICH PAYMENTS WILL BE CALCULATED, BY SUBMITTING A REQUEST IN
WRITING OR BY SUBMITTING A REQUEST VIA ELECTRONIC MEANS; AND
  (H) THAT THE PROVIDER WILL BE ABLE TO OBTAIN THE MOST CURRENT INFORMA-
TION  MAINTAINED  BY  THE PLAN REGARDING THE ELIGIBILITY OF A PARTICULAR
PATIENT TO RECEIVE COVERED SERVICES. A VIOLATION OR FAILURE  TO  PERFORM
ANY OBLIGATION IMPOSED UNDER THIS SECTION SHALL RESULT IN A CIVIL PENAL-
TY  NOT  TO  EXCEED  ONE  THOUSAND  DOLLARS  FOR  EACH SUCH VIOLATION OR
FAILURE.
  S 6. This act shall take effect on the sixtieth  day  after  it  shall
have become a law.

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