S T A T E O F N E W Y O R K
________________________________________________________________________
7920
2017-2018 Regular Sessions
I N A S S E M B L Y
May 19, 2017
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Introduced by M. of A. LAVINE, GOTTFRIED, COOK, ABINANTI, ARROYO,
RIVERA, McKEVITT -- 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.
§ 2. This act shall take effect immediately.
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD11795-01-7