senate Bill S6445

2013-2014 Legislative Session

Relates to insurer recovery 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 24, 2014 referred to insurance

S6445 - Bill Details

See Assembly Version of this Bill:
A5145
Current Committee:
Senate Insurance
Law Section:
Insurance Law
Laws Affected:
Amd ยง3224-b, Ins L
Versions Introduced in Previous Legislative Sessions:
2011-2012: A1538
2009-2010: A10850

S6445 - Bill Texts

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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.

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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
extraordinary legal and other expert costs. As a result, health care
providers are often intimidated into settling the dispute.

It can be burdensome and harassing to require a physician to defend
bills submitted and paid two years back. Health plans should act expe-
ditiously if they have reasonable demands for recouping overpayments.

PRIOR LEGISLATIVE HISTORY:

2010: A.10850 - referred to Insurance Committee
2011-2012: A.1538 - referred to Insurance Committee

FISCAL IMPLICATIONS:

None.

EFFECTIVE DATE:

Immediately.

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                    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.
                                                           LBD00944-01-3

S. 6445                             2

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.

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