|Assembly Actions - Lowercase
Senate Actions - UPPERCASE
|Jan 24, 2014||referred to insurance|
senate Bill S6445
Archive: Last Bill Status - In Senate Committee
- In Committee
- On Floor Calendar
- Passed Senate
- Passed Assembly
- Delivered to Governor
- Signed/Vetoed by Governor
S6445 - Details
S6445 - Summary
Relates to insurer recovery from health care providers; provides that except where there is a reasonable belief of fraud or intentional misconduct, a health plan shall not determine an overpayment amount through the use of extrapolation except with the consent of the health care provider.
S6445 - Sponsor Memo
BILL NUMBER:S6445 TITLE OF BILL: An act to amend the insurance law, in relation to insur- er recovery from health care providers PURPOSE OR GENERAL IDEA OF BILL: To enable fair and equitable resolution of allegations by insurers that a health care professional has been overpaid for a benefit claim. SUMMARY OF SPECIFIC PROVISIONS: The bill would amend section 3224-b of the insurance law to prohibit the use of extrapolation to determine amounts overpaid except in instances where there is a reasonable belief of fraud or intentional misconduct, to prohibit threats of retribution against health care professionals who challenge allegations of overpayment, and to require health plans to initiate overpayment proceedings within 12 months (instead of the current 24) of the payment. JUSTIFICATION: In some instances, health plans use the practice of extrapolation of a relatively few claims to determine overpayment amounts that can stretch into tens of thousands, and perhaps even hundreds of thousands, of dollars. Contesting a refund demand is difficult, and results in
S6445 - Bill Text download pdf
S T A T E O F N E W Y O R K ________________________________________________________________________ 6445 I N S E N A T E January 24, 2014 ___________ Introduced by Sen. RIVERA -- read twice and ordered printed, and when printed to be committed 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.] (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 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets [ ] is old law to be omitted.
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