S T A T E O F N E W Y O R K
________________________________________________________________________
5782
2017-2018 Regular Sessions
I N S E N A T E
April 28, 2017
___________
Introduced by Sen. PERALTA -- read twice and ordered printed, and when
printed to be committed to the Committee on Labor
AN ACT to amend the workers' compensation law, in relation to payment of
bills for pharmaceutical services
THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM-
BLY, DO ENACT AS FOLLOWS:
Section 1. Section 13-g of the workers' compensation law, as added by
chapter 258 of the laws of 1935, subdivision 1 as amended by chapter 674
of the laws of 1994, subdivisions 2 and 3 as amended by section 4 of
part GG of chapter 57 of the laws of 2013, subdivision 4 as amended by
section 3 of part D of chapter 55 of the laws of 2015, subdivision 5 as
amended by chapter 578 of the laws of 1959, and subdivision 6 as amended
by chapter 639 of the laws of 1996, is amended to read as follows:
§ 13-g. Payment of bills for medical care. (1) Within forty-five days
after a bill has been rendered to the employer by the hospital, physi-
cian, PHARMACIST, or self-employed physical or occupational therapist
who has rendered treatment OR DISPENSED MEDICATION pursuant to a refer-
ral OR PRESCRIPTION from the injured employee's authorized physician or
authorized podiatrist for treatment to the injured employee, such
employer must pay the bill or notify the hospital, physician, PHARMA-
CIST, or self-employed physical or occupational therapist in writing
that the bill is not being paid and explain the reasons for non-payment.
In the event that the employer fails to make payment or notify the
hospital, physician, PHARMACIST, or self-employed physical or occupa-
tional therapist within such forty-five day period that payment is not
being made, the hospital, physician, PHARMACIST, self-employed physical
therapist or self-employed occupational therapist may notify the chair
in writing that the bill has not been paid and request that the board
make an award for payment of such bill. The board or the chair may make
an award not in excess of the established fee schedules for any such
bill or part thereof which remains unpaid after said forty-five day
EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD01659-01-7
S. 5782 2
period or thirty days after all other questions duly and timely raised
in accordance with the provisions of this chapter, relating to the
employer's liability for the payment of such amount, shall have been
finally determined adversely to the employer, whichever is later, in
accordance with rules promulgated by the chair, and such award may be
collected in like manner as an award of compensation. The chair shall
assess the sum of fifty dollars against the employer for each such award
made by the board, which sum shall be paid into the state treasury.
In the event that the employer has provided an explanation in writing
why the bill has not been paid, in part or in full, within the aforesaid
time period, and the parties [can not] CANNOT agree as to the value of
medical aid rendered under this chapter, such value shall be decided by
arbitration if requested by the hospital, physician, PHARMACIST, or
self-employed physical or occupational therapist, in accordance with the
provisions of subdivision two or subdivision three of this section, as
appropriate, and rules and regulations promulgated by the chair.
Where a physician, PHARMACIST, OR physical or occupational therapist
bill has been determined to be due and owing in accordance with the
provisions of this section the board shall include in the amount of the
award interest of not more than one and one-half per cent (1 1/2%) per
month payable to the physician, PHARMACIST, OR physical or occupational
therapist, in accordance with the rules and regulations promulgated by
the board. Interest shall be calculated from the forty-fifth day after
the bill was rendered or from the thirtieth day after all other ques-
tions duly and timely raised in accordance with the provisions of this
chapter, relating to the employer's liability for the payment of such
amount, shall have been finally determined adversely to the employer,
whichever is later, in accordance with rules promulgated by the chair.
(2) (a) If the parties fail to agree to the value of medical aid
rendered under this chapter and the amount of the disputed bill is one
thousand dollars or less, or if the amount of the disputed medical bill
exceeds one thousand dollars and the health care provider expressly so
requests, such value shall be decided by a single arbitrator process,
pursuant to rules promulgated by the chair. The chair shall appoint a
physician who is a member in good standing of the medical society of the
state of New York to determine the value of such disputed medical bill.
Where the physician whose charges are being arbitrated is a member in
good standing of the New York osteopathic society, the value of such
disputed bill shall be determined by a member in good standing of the
New York osteopathic society appointed by the chair. Where the physician
whose charges are being arbitrated is a member in good standing of the
New York homeopathic society, the value of such disputed bill shall be
determined by a member in good standing of the New York homeopathic
society appointed by the chair. Where the value of physical therapy
services or occupational therapy services is at issue, such value shall
be determined by a member in good standing of a recognized professional
association representing its respective profession in the state of New
York appointed by the chair. Decisions rendered under the single arbi-
trator process shall be conclusive upon the parties as to the value of
the services in dispute.
(b) If the parties fail to agree as to the value of medical aid
rendered under this chapter and the amount of the disputed bill exceeds
one thousand dollars, such value shall be decided by an arbitration
committee unless the health care provider expressly requests a single
arbitrator process in accordance with paragraph (a) of this subdivision.
The arbitration committee shall consist of one physician designated by
S. 5782 3
the president of the medical society of the county in which the medical
services were rendered, one physician who is a member of the medical
society of the state of New York, appointed by the employer or carrier,
and one physician, also a member of the medical society of the state of
New York, appointed by the chair of the workers' compensation board. If
the physician whose charges are being arbitrated is a member in good
standing of the New York osteopathic society or the New York homeopathic
society, the members of such arbitration committee shall be physicians
of such organization, one to be appointed by the president of that
organization, one by the employer or carrier and the third by the chair
of the workers' compensation board. Where the value of physical therapy
services is at issue and the amount of the disputed bill exceeds one
thousand dollars, the arbitration committee shall consist of a member in
good standing of a recognized professional association representing
physical therapists in the state of New York appointed by the president
of such organization, a physician designated by the employer or carrier
and a physician designated by the chair of the workers' compensation
board provided however, that the chair finds that there are a sufficient
number of physical therapy arbitrations in a geographical area comprised
of one or more counties to warrant a committee so comprised. In all
other cases where the value of physical therapy services is at issue and
the amount of the disputed bill exceeds one thousand dollars, the arbi-
tration committee shall be similarly selected and identical in composi-
tion, provided that the physical therapist member shall serve without
remuneration, and provided further that in the event a physical thera-
pist is not available, the committee shall be comprised of three physi-
cians designated in the same manner as in cases where the value of
medical aid is at issue.
(c) Where the value of occupational therapy services is at issue the
arbitration committee shall consist of a member in good standing of a
recognized professional association representing occupational therapists
in the state of New York appointed by the president of such organiza-
tion; a physician designated by the employer or carrier and a physician
designated by the chair of the workers' compensation board provided,
however, that the chair finds that there are a sufficient number of
occupational therapy arbitrations in a geographical area comprised of
one or more counties to warrant a committee so comprised. In all other
cases where the value of occupational therapy services is at issue and
the amount of the disputed bill exceeds one thousand dollars, the arbi-
tration committee shall be similarly selected and identical in composi-
tion, provided that the occupational therapist member shall serve with-
out remuneration, and provided further that in the event an occupational
therapist is not available, the committee shall be comprised of three
physicians designated in the same manner as in cases where the value of
medical aid is at issue. The majority decision of any such arbitration
committee shall be conclusive upon the parties as to the value of the
services in dispute.
(3) (a) If an employer shall have notified the hospital in writing, as
provided in subdivision one of this section, why the bill has not been
paid, in part or in full, and the amount of the disputed bill is one
thousand dollars or less, or where the amount of the disputed medical
bill exceeds one thousand dollars and the hospital expressly so
requests, such value shall be decided by a single arbitrator process,
pursuant to rules promulgated by the chair. The chair shall appoint a
physician in good standing licensed to practice in New York state to
determine the value of such disputed bill. Decisions rendered under the
S. 5782 4
administrative resolution procedure shall be conclusive upon the parties
as to the value of the services in dispute.
(b) If an employer shall have notified the hospital in writing, as
provided in subdivision one of this section, why the bill has not been
paid, in part or in full, and the amount of the disputed bill exceeds
one thousand dollars, the value of such bill shall be determined by an
arbitration committee appointed by the chair for that purpose, which
committee shall consider all of the charges of the hospital, unless the
hospital expressly requests a single arbitrator process pursuant to
paragraph (a) of this subdivision. The committee shall consist of three
physicians. One member of the committee may be nominated by the chair
upon recommendation of the president of the hospital association of New
York state and one member may be nominated by the employer or insurance
carrier. The majority decision of any such committee shall be conclusive
upon the parties as to the value of the services rendered. The chair may
make reasonable rules and regulations consistent with the provisions of
this section.
(4) (A) IF AN EMPLOYER SHALL HAVE NOTIFIED THE PHARMACIST IN WRITING,
AS PROVIDED IN SUBDIVISION ONE OF THIS SECTION, WHY THE BILL HAS NOT
BEEN PAID, IN PART OR IN FULL, AND THE PHARMACIST EXPRESSLY SO REQUESTS,
THE VALUE AND LIABILITY SHALL BE DECIDED BY A SINGLE ARBITRATOR PROCESS,
PURSUANT TO RULES PROMULGATED BY THE CHAIR. THE CHAIR SHALL APPOINT A
PHARMACIST IN GOOD STANDING LICENSED TO PRACTICE IN NEW YORK STATE TO
DETERMINE THE VALUE AND LIABILITY OF SUCH DISPUTED BILL. DECISIONS
RENDERED UNDER THE ADMINISTRATIVE RESOLUTION PROCEDURE SHALL BE CONCLU-
SIVE UPON THE PARTIES AS TO THE VALUE AND LIABILITY OF THE PRESCRIPTION
IN DISPUTE.
(B) IF AN EMPLOYER SHALL HAVE NOTIFIED THE PHARMACIST IN WRITING, AS
PROVIDED IN SUBDIVISION ONE OF THIS SECTION, WHY THE BILL HAS NOT BEEN
PAID, IN PART OR IN FULL, THE AMOUNT OF THE DISPUTED BILL EXCEEDS FIVE
HUNDRED DOLLARS, AND THE BILL HAS A COMMON VENDOR, PROVIDER, AND PAYER,
THE VALUE OF SUCH BILL SHALL BE DETERMINED BY AN ARBITRATION COMMITTEE
APPOINTED BY THE CHAIR FOR THAT PURPOSE, WHICH COMMITTEE SHALL CONSIDER
ALL OF THE CHARGES OF THE PHARMACIST, UNLESS THE PHARMACIST EXPRESSLY
REQUESTS A SINGLE ARBITRATOR PROCESS PURSUANT TO PARAGRAPH (A) OF THIS
SUBDIVISION. THE ARBITRATION COMMITTEE SHALL CONSIST OF THREE PHARMA-
CISTS IN GOOD STANDING LICENSED TO PRACTICE IN NEW YORK STATE TO DETER-
MINE THE VALUE AND LIABILITY OF SUCH DISPUTED BILL. ONE MEMBER OF THE
COMMITTEE MAY BE NOMINATED BY THE CHAIR, ONE MEMBER MAY BE NOMINATED BY
THE PROFESSIONAL PHARMACY ASSOCIATION AFFILIATED WITH THE COMPLAINANT
AND ONE MEMBER MAY BE NOMINATED BY THE EMPLOYER OR INSURANCE CARRIER.
THE MAJORITY DECISION OF ANY SUCH COMMITTEE SHALL BE CONCLUSIVE UPON THE
PARTIES AS TO THE VALUE OF THE SERVICES RENDERED. THE CHAIR SHALL MAKE
REASONABLE RULES AND REGULATIONS CONSISTENT WITH THE PROVISIONS OF THIS
SECTION.
(5) A provider initiating an arbitration, including a single arbitra-
tor process, pursuant to this section shall not pay a fee to cover the
costs related to the conduct of such arbitration. Each member of an
arbitration committee for medical bills, [and] each member of an arbi-
tration committee for hospital bills AND EACH MEMBER OF AN ARBITRATION
COMMITTEE FOR PHARMACY BILLS shall be entitled to receive and shall be
paid a fee for each day's attendance at an arbitration session in any
one count in an amount fixed by the chair of the workers' compensation
board.
[(5)] (6) In claims where the employer has failed to secure compen-
sation to his OR HER employees as required by section fifty of this
S. 5782 5
chapter, the board may make an award for the value of medical and podia-
try services or treatment rendered to such employees, in accordance with
the schedules of fees and charges prepared and established under the
provisions of section thirteen, subdivision a, and section thirteen-k,
subdivision two, of this chapter, and for the reasonable value of hospi-
tal care in accordance with the charges currently in force in hospitals
in the same community for cases coming within the provisions of this
chapter. Such award shall be made to the physician, podiatrist, or
hospital entitled thereto. A default in the payment of such award may be
enforced in the manner provided for the enforcement of compensation
awards as set forth in section twenty-six of this [chapter] ARTICLE.
In all cases coming under this subdivision the payment of the claim of
the physician, podiatrist, or hospital for medical, podiatry, or surgi-
cal services or treatment shall be subordinate to that of the claimant
or his OR HER beneficiaries.
[(6)] (7) Notwithstanding any inconsistent provision of law, arbi-
tration regarding payments for inpatient hospital services for any
patient discharged on or after January first, nineteen hundred ninety-
one and prior to December thirty-first, nineteen hundred ninety-six
shall be resolved in accordance with paragraph (d) of subdivision three
of section twenty-eight hundred seven-c of the public health law.
§ 2. The chair of the workers' compensation board shall promulgate
such regulations as he or she deems appropriate to carry out the
purposes of this act. Such regulations may include, but are not limited
to, what defenses, if any, may be available to employers or carriers in
arbitration to determine the value or liability of a pharmaceutical bill
pursuant to the provisions of this act.
§ 3. This act shall take effect on the one hundred twentieth day after
it shall have become a law; provided that, effective immediately, the
addition, amendment, and/or repeal of any rules and regulations neces-
sary to implement the provisions of this act on its effective date are
authorized and directed to be completed on or before such effective
date.
