Assembly Bill A3088C

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

                                  3088

                       2013-2014 Regular Sessions

                          I N  A S S E M B L Y

                            January 23, 2013
                               ___________

Introduced  by  M. of A. LAVINE, COOK, ARROYO, DUPREY, GIBSON, McKEVITT,
  MONTESANO, RIVERA, ROBERTS -- read once and referred to the  Committee
  on Insurance

AN ACT to amend the insurance law, in relation to recoveries of overpay-
  ments to health care providers

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

  Section 1. Paragraphs 4 and 5 of subsection (b) of section  3224-b  of
the  insurance law are renumbered paragraphs 5 and 6 and a new paragraph
4 is added to read as follows:
  (4) A HEALTH PLAN SHALL NOT DETERMINE AN OVERPAYMENT  RECOVERY  AMOUNT
THROUGH  THE  USE  OF  EXTRAPOLATION,  EXCEPT WHERE THERE IS EVIDENCE OF
FRAUD OR INTENTIONAL MISCONDUCT.
  S 2. This act shall take effect immediately.






 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD06450-01-3


              

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

                                 3088--A

                       2013-2014 Regular Sessions

                          I N  A S S E M B L Y

                            January 23, 2013
                               ___________

Introduced  by  M. of A. LAVINE, COOK, ARROYO, DUPREY, GIBSON, McKEVITT,
  MONTESANO, RIVERA, ROBERTS, GOTTFRIED -- read once and referred to the
  Committee on Insurance -- committee discharged, bill amended,  ordered
  reprinted as amended and recommitted to said committee

AN ACT to amend the insurance law, in relation to recoveries of overpay-
  ments to health care providers

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

  Section 1. Paragraphs 4 and 5 of subsection (b) of section  3224-b  of
the  insurance law are renumbered paragraphs 5 and 6 and a new paragraph
4 is added to read as follows:
  (4) A HEALTH PLAN SHALL NOT DETERMINE AN OVERPAYMENT  RECOVERY  AMOUNT
THROUGH  THE  USE  OF  EXTRAPOLATION,  EXCEPT WHERE THERE IS EVIDENCE OF
FRAUD OR INTENTIONAL MISCONDUCT.  A FINDING OF OVERPAYMENT OR  UNDERPAY-
MENT  MUST BE BASED ON THE ACTUAL OVERPAYMENT OR UNDERPAYMENT AND NOT AN
EXTRAPOLATION OR PROJECTION BASED ON THE NUMBER OF PATIENTS SERVED OR ON
THE NUMBER OF PATIENTS ENROLLED IN THAT NETWORK PROVIDER.
  S 2. This act shall take effect immediately.





 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD06450-02-3


              

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

                                 3088--B

                       2013-2014 Regular Sessions

                          I N  A S S E M B L Y

                            January 23, 2013
                               ___________

Introduced  by M. of A. LAVINE, COOK, ARROYO, DUPREY, McKEVITT, MONTESA-
  NO, RIVERA, ROBERTS, GOTTFRIED, SCHIMEL -- Multi-Sponsored by -- M. of
  A. PERRY -- read once and referred to the Committee  on  Insurance  --
  committee  discharged,  bill amended, ordered reprinted as amended and
  recommitted to said committee  --  recommitted  to  the  Committee  on
  Insurance  in  accordance  with  Assembly  Rule 3, sec. 2 -- committee
  discharged, bill amended, ordered reprinted as amended and recommitted
  to said committee

AN ACT to amend the insurance law, in relation to determination of over-
  payments to health care providers by extrapolation

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

  Section  1.  Paragraph  2  of  subsection (b) of section 3224-b of the
insurance law, as amended by chapter 237 of the laws of 2009, is amended
to read as follows:
  (2) [A health plan shall provide  a  health  care  provider  with  the
opportunity  to challenge an overpayment recovery, including the sharing
of claims information, and shall establish written policies  and  proce-
dures  for  health  care providers to follow to challenge an overpayment
recovery. Such challenge shall set forth the specific grounds  on  which
the  provider is challenging the overpayment recovery] IN THE EVENT THAT
THE PROCESS KNOWN AS EXTRAPOLATION WILL BE USED IN  DETERMINING  WHETHER
HEALTH  CARE  PROVIDERS  HAVE  RECEIVED  OVERPAYMENTS FROM A HEALTH CARE
PLAN, THE HEALTH CARE PLAN SHALL COMPLY WITH THE FOLLOWING REQUIREMENTS:
  (A) ADVISE THE HEALTH CARE PROVIDER WITH WRITTEN NOTICE THAT  EXTRAPO-
LATION WILL BE UTILIZED;
  (B)  APPLY A VALID STATISTICAL METHODOLOGY THAT USES STRATIFIED RANDOM
SAMPLING METHODS TO ASSURE A FAIR EVALUATION OF THE  CLAIMS  SUBJECT  TO
AUDIT;
  (C)  ADVISE  THE  HEALTH  CARE  PROVIDER AS TO THE TYPE OF METHODOLOGY
USED;

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD06450-05-4
              

A. 3088--B                          2

  (D) PROVIDE THE HEALTH CARE PROVIDER SIXTY BUSINESS DAYS TO APPEAL THE
AUDIT FINDINGS; AND
  (E)  IN  THE EVENT OF AN APPEAL OF THE AUDIT FINDINGS, THE HEALTH CARE
PROVIDER MAY SEEK A REVIEW OF THE FINDINGS BY  A  MUTUALLY  AGREED  UPON
INDEPENDENT  THIRD PARTY AUDITOR. THE COST OF A THIRD PARTY REVIEW SHALL
BE SHARED EQUALLY BETWEEN THE PARTIES.
  S 2. This act shall take effect immediately.