Assembly Bill A1193

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

                                  1193

                       2015-2016 Regular Sessions

                          I N  A S S E M B L Y

                             January 8, 2015
                               ___________

Introduced  by  M. of A. LAVINE, COOK, SCHIMEL, ABINANTI, ARROYO, McKEV-
  ITT, DUPREY, ROBERTS, GOTTFRIED, RIVERA -- Multi-Sponsored by -- M. of
  A. PERRY -- read once and referred to the Committee on Insurance

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 oppor-
tunity to challenge an overpayment recovery, including  the  sharing  of
claims  information, and shall establish written policies and procedures
for health care providers to follow to challenge an  overpayment  recov-
ery.  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;
  (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.

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
              

                      [ ] is old law to be omitted.
                                                           LBD03090-01-5