S T A T E O F N E W Y O R K
________________________________________________________________________
1538
2011-2012 Regular Sessions
I N A S S E M B L Y
January 10, 2011
___________
Introduced by M. of A. GOTTFRIED, LAVINE, MAGNARELLI, GALEF, BURLING,
PAULIN, JACOBS, SCHIMEL, HIKIND, LIFTON, JAFFEE, ZEBROWSKI, MONTESANO,
McDONOUGH, LANCMAN, SCARBOROUGH -- Multi-Sponsored by -- M. of A.
GLICK, McENENY, PHEFFER, REILLY, 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.
LBD05377-01-1
A. 1538 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.