senate Bill S5155

2013-2014 Legislative Session

Relates to the provisional credentialing of physicians

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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 08, 2014 referred to insurance
May 13, 2013 referred to insurance

S5155 - Bill Details

See Assembly Version of this Bill:
A7569
Current Committee:
Law Section:
Insurance Law
Laws Affected:
Amd §4803, Ins L; amd §4406-d, Pub Health L

S5155 - Bill Texts

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Relates to the provisional credentialing of physicians.

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BILL NUMBER:S5155

TITLE OF BILL: An act to amend the insurance law and the public
health law, in relation to provider credentialing

PURPOSE: The purpose of this bill is to permit newly licensed
providers, providers moving to New York State, or a physician who has
changed their corporate relationship such that it results in the
issuance of a new tax identification number under which their services
are billed for, who are employed by licensed Article 28 facilities and
have applied to be credentialed as part of a health plan's provider
network to be considered provisionally credentialed from the date the
health plan receives the hospital and physicians completed sections of
the plan's credentialing application and the plan is notified in
writing that the physician has been granted hospital privileges .

SUMMARY OF PROVISIONS:

Section 1 of the bill amends subsection (a) of Section 4803 of the
insurance law by adding a new paragraph (3) that provides that newly
licensed physicians, physicians that have recently relocated to the
state or a physician who has changed their corporate relationship such
that it results in the issuance of a new tax identification number
under which their services are billed for, who are employed by a
licensed Article 28 facility whose other employed health care
professionals participate in the in-network portion of a health plan's
network shall be considered provisionally credentialed from the date
the health insurer receives the hospital and physician's completed
sections of the insurer's credentialing application and the insurer is
notified in writing that the physician has been granted hospital
privileges.

Section 2 amends Subsection 1 of Section 446-d of the public health
law by adding a new paragraph (c) that provides that newly licensed
physicians, physicians that have recently relocated to the state or a
physician who has changed their corporate relationship such that it
results in the issuance of a new tax identification number under which
their services are billed for, who are employed by a licensed Article
28 facility whose other employed health care professionals participate
in the in-network portion of a health plan's network shall be
considered provisionally credentialed from the date the health plan
receives the hospital and physician's completed sections of the plan's
credentialing application and the plan is notified in writing that the
physician has been granted hospital privileges.

Section 3 is the effective date.

EXISTING LAW: The latest of the managed care reform laws (Chapter 237
of the Laws of 2009) provided that newly licensed health care
professionals or health care professionals that recently relocated to
New York State who joined a group practice of health care
professionals and have applied to be credentialed as part of the
in-network of a health plan's network are considered provisionally
credentialed if their application is not approved or denied with 90
days from the date of application.


JUSTIFICATION: The model of care delivery is gradually shifting from
a physician private practice model to a model of hospital or health
system employed physicians. In fact, a leading physician recruiting
firms (Merritt Hawkins) has predicted that by 2015, over 75% of newly
hired physicians will be hospital employees. In order to recruit and
retain physicians, upstate hospitals in a market of increasing
physician shortage have been forced to be at the forefront of this
shifting model of care. However, faced with increasingly constrained
revenue from Medicare and Medicaid cuts and commercial health plans,
hospitals, who most often lose money on physicians services component
of care even with full payment, cannot carry afford to carry a
physician on salary for 90 days without reimbursement for their
services nor based on the physician shortage can they afford to be
without the services of these physicians.

Hospitals as licensed and regulated Article 28 facilities are
statutorily required to credential any provider before extending
admitting privileges or allowing the professional to provide care
within the facility. According to both hospitals and health plan
administrators it is almost unheard of for a hospital itself to employ
any physician who would be unsuitable for health plan credentialing.

All too often credentialing decisions and notification are delayed by
simple administrative processes such has the delayed paperwork or the
next scheduled meeting of the health plan's credentialing committee,
The legislation would allow the hospitals to maximize the use of
scarce health manpower and to be reimbursed for the services their
employed physicians provide. The bill also provide for strict
financial controls whereby the payments for all services provided to
the health plans' enrollees are held and only after the health plan
fully credentials the provider, are the payments for services rendered
transmitted. Should a health plan, in rare cases, and for valid
reasons elect not to credential a hospital employed physician then the
payments to the hospital by the health plan are limited to the out of
network payment, should the enrollee have coverage for out-of-network
care.

LEGISLATIVE HISTORY: New Bill

FISCAL IMPLICATIONS: None

LOCAL FISCAL IMPLICATIONS: None

EFFECTIVE DATE: This bill is effective ninety days after which it
shall have become law, and applies to applications submitted after
that date, and shall not apply submitted prior to such date if such
application is resubmitted in substantially similar form on or after
the date on which this act shall have become law.

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

                                  5155

                       2013-2014 Regular Sessions

                            I N  S E N A T E

                              May 13, 2013
                               ___________

Introduced  by  Sen. VALESKY -- 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 provider credentialing

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

  Section  1.  Subsection  (a)  of  section 4803 of the insurance law is
amended by adding a new paragraph 3 to read as follows:
  (3) A NEWLY-LICENSED PHYSICIAN, A PHYSICIAN WHO HAS RECENTLY RELOCATED
TO THIS STATE FROM ANOTHER STATE AND HAS  NOT  PREVIOUSLY  PRACTICED  IN
THIS  STATE,  OR  A  PHYSICIAN  WHO  HAS  CHANGED  HIS  OR HER CORPORATE
RELATIONSHIP SUCH THAT IT RESULTS IN THE ISSUANCE OF A NEW TAX IDENTIFI-
CATION NUMBER UNDER WHICH SUCH PHYSICIAN'S SERVICES ARE BILLED FOR,  WHO
IS   EMPLOYED  BY  A  GENERAL  HOSPITAL  LICENSED  PURSUANT  TO  ARTICLE
TWENTY-EIGHT OF THE PUBLIC HEALTH LAW, AND WHOSE OTHER  EMPLOYED  PHYSI-
CIANS  PARTICIPATE  IN THE IN-NETWORK   PORTION OF AN INSURER'S NETWORK,
SHALL BE DEEMED "PROVISIONALLY CREDENTIALED"  AND MAY PARTICIPATE IN THE
IN-NETWORK PORTION OF AN INSURER'S NETWORK  UPON  :  (I)  THE  INSURER'S
RECEIPT OF THE HOSPITAL AND PHYSICIAN'S COMPLETED SECTIONS OF THE INSUR-
ER'S  CREDENTIALING  APPLICATION; AND (II) THE INSURER BEING NOTIFIED IN
WRITING THAT THE HEALTH CARE  PROFESSIONAL  HAS  BEEN  GRANTED  HOSPITAL
PRIVILEGES  PURSUANT  TO  THEIR  REQUIREMENTS  OF  SECTION  TWENTY-EIGHT
HUNDRED FIVE-K OF  THE  PUBLIC  HEALTH  LAW.  HOWEVER,  A  PROVISIONALLY
CREDENTIALED  PHYSICIAN  SHALL NOT BE DESIGNATED AS AN INSURED'S PRIMARY
CARE PHYSICIAN UNTIL SUCH TIME AS THE PHYSICIAN HAS BEEN  FULLY  CREDEN-
TIALED  BY  THE  INSURER.  AN  INSURER SHALL NOT BE REQUIRED TO MAKE ANY
PAYMENTS TO THE LICENSED GENERAL HOSPITAL FOR  SERVICES  PROVIDED  BY  A
PROVISIONALLY  CREDENTIALED PHYSICIAN, UNTIL AND UNLESS THE PHYSICIAN IS
FULLY CREDENTIALED BY THE INSURER, PROVIDED, HOWEVER,  THAT  UPON  BEING
FULLY  CREDENTIALED, THE LICENSED GENERAL HOSPITAL SHALL BE PAID FOR ALL
SERVICES THAT THE  CREDENTIALED  PHYSICIAN  PROVIDED  TO  THE  INSURER'S

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD10913-01-3

S. 5155                             2

INSUREDS  FROM  THE  DATE THE PHYSICIAN FULLY MET THE REQUIREMENTS TO BE
PROVISIONALLY CREDENTIALED PURSUANT TO THIS PARAGRAPH. SHOULD THE APPLI-
CATION ULTIMATELY BE DENIED BY THE INSURER, THE  INSURER  SHALL  NOT  BE
LIABLE FOR ANY PAYMENT TO THE LICENSED GENERAL HOSPITAL FOR THE SERVICES
PROVIDED BY THE PROVISIONALLY CREDENTIALED HEALTH CARE PROFESSIONAL THAT
EXCEED  ANY OUT-OF-NETWORK BENEFITS PAYABLE UNDER THE INSURED'S CONTRACT
WITH THE INSURER; AND THE LICENSED GENERAL  HOSPITAL  SHALL  NOT  PURSUE
REIMBURSEMENT FORM THE INSURED, EXCEPT TO COLLECT THE COPAYMENT OR COIN-
SURANCE  THAT OTHERWISE WOULD HAVE BEEN PAYABLE HAD THE INSURED RECEIVED
SERVICES FROM A HEALTH CARE PROFESSIONAL PARTICIPATING IN THE IN-NETWORK
PORTION OF AN INSURER'S NETWORK.
  S 2. Subdivision 1 of section 4406-d  of  the  public  health  law  is
amended by adding a new paragraph (c) to read as follows:
  (C) A NEWLY-LICENSED PHYSICIAN, A PHYSICIAN WHO HAS RECENTLY RELOCATED
TO  THIS  STATE  FROM  ANOTHER STATE AND HAS NOT PREVIOUSLY PRACTICED IN
THIS STATE, OR  A  PHYSICIAN  WHO  HAS  CHANGED  HIS  OR  HER  CORPORATE
RELATIONSHIP SUCH THAT IT RESULTS IN THE ISSUANCE OF A NEW TAX IDENTIFI-
CATION  NUMBER UNDER WHICH SUCH PHYSICIAN'S SERVICES ARE BILLED FOR, WHO
IS  EMPLOYED  BY  A  GENERAL  HOSPITAL  LICENSED  PURSUANT  TO   ARTICLE
TWENTY-EIGHT  OF  THIS  CHAPTER,  AND  WHOSE  OTHER  EMPLOYED PHYSICIANS
PARTICIPATE IN THE IN-NETWORK PORTION OF A HEALTH CARE  PLAN'S  NETWORK,
SHALL BE DEEMED "PROVISIONALLY CREDENTIALLED" AND MAY PARTICIPATE IN THE
IN-NETWORK  PORTION OF A HEALTH CARE PLAN'S NETWORK UPON: (I) THE PLAN'S
RECEIPT OF THE HOSPITAL AND PHYSICIAN'S COMPLETED SECTION OF THE  PLAN'S
CREDENTIALING  APPLICATION; AND (II) THE HEALTH CARE PLAN BEING NOTIFIED
IN WRITING THAT THE HEALTH CARE PROFESSIONAL HAS BEEN  GRANTED  HOSPITAL
PRIVILEGE  PURSUANT  TO THE REQUIREMENTS OF SECTION TWENTY-EIGHT HUNDRED
FIVE-K OF THIS CHAPTER. HOWEVER, A PROVISIONALLY CREDENTIALED  PHYSICIAN
SHALL  NOT  BE  DESIGNATED AS AN ENROLLEE'S PRIMARY CARE PHYSICIAN UNTIL
SUCH TIME AS THE PHYSICIAN HAS BEEN FULLY  CREDENTIALED  BY  THE  HEALTH
CARE PLAN. A HEALTH CARE PLAN SHALL NOT BE REQUIRED TO MAKE ANY PAYMENTS
TO  THE  LICENSED  GENERAL  HOSPITAL  FOR  SERVICED PROVIDED BY A PROVI-
SIONALLY CREDENTIALED PHYSICIAN, UNTIL AND UNLESS THE PHYSICIAN IS FULLY
CREDENTIALED BY THE HEALTH CARE PLAN, PROVIDED HOWEVER THAT  UPON  BEING
FULLY  CREDENTIALED, THE LICENSED GENERAL HOSPITAL SHALL BE PAID FOR ALL
SERVICES THAT THE CREDENTIALED PHYSICIAN PROVIDED TO THE  HEALTH  PLAN'S
ENROLLEES  FROM  THE DATE THE PHYSICIAN FULLY MET THE REQUIREMENTS TO BE
PROVISIONALLY CREDENTIALED PURSUANT TO THIS PARAGRAPH. SHOULD THE APPLI-
CATION ULTIMATELY BE DENIED BY THE HEALTH CARE  PLAN,  THE  HEALTH  CARE
PLAN  SHALL NOT BE LIABLE FOR ANY PAYMENT TO THE LICENSED GENERAL HOSPI-
TAL FOR THE SERVICES PROVIDED BY THE PROVISIONALLY  CREDENTIALED  HEALTH
CARE  PROFESSIONAL THAT EXCEED ANY OUT-OF-NETWORK BENEFITS PAYABLE UNDER
THE ENROLLEE'S CONTRACT WITH THE  HEALTH  CARE  PLAN  AND  THE  LICENSED
GENERAL  HOSPITAL  SHALL  NOT  PURSUE  REIMBURSEMENT  FORM THE ENROLLEE,
EXCEPT TO COLLECT THE COPAYMENT OR COINSURANCE THAT OTHERWISE WOULD HAVE
BEEN PAYABLE HAD THE ENROLLEE  RECEIVED  SERVICES  FROM  A  HEALTH  CARE
PROFESSIONAL  PARTICIPATING  IN  THE  IN-NETWORK PORTION OF AN INSURER'S
NETWORK.
  S 3. This act shall take effect on the ninetieth day  after  it  shall
have become a law, and shall apply to applications submitted on or after
such  date  and  shall not apply to applications submitted prior to such
date if such application is resubmitted in substantially similar form on
or after the effective date of this act.

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