NY State Senate Bill 2021-S4047

Archive: Last Bill Status - In Senate Committee Insurance Committee

Introduced
- In Committee Assembly
- In Committee Senate
- On Floor Calendar Assembly
- On Floor Calendar Senate
- Passed Assembly
- Passed Senate
Delivered to Governor
Signed By Governor

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Date of Action	Assembly Actions - Lowercase Senate Actions - UPPERCASE
Jan 05, 2022	referred to insurance
Feb 01, 2021	referred to insurance

co-Sponsors

2021-S4047 (ACTIVE) - Details

Current Committee:: Senate Insurance
Law Section:: Insurance Law
Laws Affected:: Amd §§5108 & 5106, Ins L
Versions Introduced in Other Legislative Sessions:: 2011-2012: S6706
2013-2014: S3546
2015-2016: S2370
2017-2018: S780
2019-2020: S3514
2023-2024: S3550

2021-S4047 (ACTIVE) - Summary

Relates to providing for the use of treatment guidelines in the no-fault system; prohibits insurers from paying any charge which exceeds the applicable fee schedule or which is not provided for under the fee schedule or compensable under Medicare.

2021-S4047 (ACTIVE) - Sponsor Memo

                                
 
BILL NUMBER: S4047

SPONSOR: BRESLIN
 
TITLE OF BILL:

An act to amend the insurance law, in relation to providing for the use
of treatment guidelines under the comprehensive motor vehicle repara-
tions act

 
PURPOSE:

To eliminate fraudulent and unnecessary medical treatment in the
no-fault system.

 
SUMMARY OF PROVISIONS:

Section 1 of this bill would require the establishment of treatment
guidelines for medical treatment provided under the no-fault system.

Section 2 of this bill would provide an expedited process for the resol-
ution of disputes regarding deviations from the treatment guidelines.

Section 3 of the bill is the effective date.

 
JUSTIFICATION:

On February 29, 2012, the Manhattan U.S. Attorney announced the indict-
ment of 36 people for participating in a $279 million no-fault fraud
scheme involving fraudulent medical clinics (medical mills). One of the
reasons why medical mills proliferate in New York is because New York's
no-fault system makes it very easy to bill insurance companies for frau-
dulent and unnecessary treatment. This bill would remedy this situation
by establishing guidelines for the treatment of various injuries common-
ly sustained in automobile accidents.

Treatment guidelines have been adopted in New Jersey for its no-fault
system and in New York for the workers compensation system. Treatment
guidelines are a valuable tool in preventing the fraudulent overutiliza-
tion of unnecessary medical treatments. Treatment guidelines are
evidence based standards of care and best practices for the medical
treatment of injuries which ensure that claimants receive the highest
duality medical treatment. In the workers compensation context, the
guidelines were initially developed by the Governor's Workers' Compen-
sation Reform Task Force and its advisory committee comprised of well
credentialed medical professionals and other interested parties. This
bill would require similar scientifically based guidelines to be devel-
oped for the treatment of injuries commonly resulting from auto acci-
dents. These guidelines would ensure that auto accident victims would
receive the best care for their injuries and, because the guidelines set
forth clear standards for treatment, they would significantly reduce
fraud and abuse in the no-fault system. Establishing treatment guide-
lines would go a long way toward putting an end to medical mills in New
York State.

New York's no fault system is plagued by fraud and abuse which is adding
significant costs to auto premiums in New York and a major contributing
factor making New Yorkers pay among the highest auto insurance premiums
in the nation. In fact, a recent Insurance Research Council study found
that in the New York City area, about one in every five no-fault auto
insurance claims closed in 2010 appear to have elements of fraud. In
addition, New York's no-fault claim. costs have far outpaced that of
other no-fault states and the overall cost of medical care. From 2004
through the 2nd Quarter of 2010, the average PIP claim cost rose 60.1
percent in New York, nearly 42 points faster than the 18.6 percent
growth rate in the Consumer Price Index cost of medical goods and
services found in the region. The cost of no-fault personal injury
protection (PIP) coverage has also soared. New York's average no-fault
PIP claim cost $9,007 is the third highest in the nation as of 2nd quar-
ter 2010.  Establishing treatment. guidelines for the no-fault system
would assist in reducing fraud in the no-fault system and the costs
associated with fraud.

 
LEGISLATIVE HISTORY:

S.3514 of 2019-20;

S.780 of 2017-18;

S.2370 of 2015-16;

S.3546 of 2013-14;

S.6706 of 2011-12

 
FISCAL IMPLICATIONS:

None.

 
EFFECTIVE DATE:
Immediately and shall apply to all actions and proceedings commenced on
or after such date; and shall also apply to any action or proceeding
which was commenced prior to such effective date where, as of such date,
a trial of the issues has not yet commenced.

2021-S4047 (ACTIVE) - Bill Text download pdf

                            
 
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   4047
 
                        2021-2022 Regular Sessions
 
                             I N  S E N A T E
 
                             February 1, 2021
                                ___________
 
 Introduced  by  Sen. BRESLIN -- 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 providing for the  use
   of  treatment guidelines under the comprehensive motor vehicle repara-
   tions act

   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:
 
   Section  1.    Section 5108 of the insurance law is amended to read as
 follows:
   § 5108. Limit on charges by providers  of  health  services.  (a)  The
 charges  for  services  specified  in paragraph one of subsection (a) of
 section five thousand one hundred two of this article  and  any  further
 health  service charges which are incurred as a result of the injury and
 which are in excess of basic economic loss, shall not exceed the charges
 permissible under the schedules prepared and established by the chairman
 of the workers' compensation  board  for  industrial  accidents,  except
 where  the  insurer  or arbitrator determines that unusual procedures or
 unique circumstances justify the excess charge, AND SHALL BE SUBJECT  TO
 THE  TREATMENT GUIDELINES ESTABLISHED PURSUANT TO SUBSECTION (D) OF THIS
 SECTION.  AT NO TIME SHALL AN INSURER PAY ANY CHARGE  THAT  EXCEEDS  THE
 CHARGES  PERMISSIBLE  UNDER THE SCHEDULE PREPARED AND ESTABLISHED BY THE
 CHAIR OF THE WORKERS' COMPENSATION BOARD.
   (b) The superintendent, after consulting  with  the  chairman  of  the
 workers'  compensation  board  and  the  commissioner  of  health, shall
 promulgate rules  and  regulations  implementing  and  coordinating  the
 provisions  of  this  article  and  the  workers'  compensation law with
 respect to charges for the professional  health  services  specified  in
 paragraph one of subsection (a) of section five thousand one hundred two
 of  this  article, including the establishment of schedules for all such
 services for which schedules have not been prepared and  established  by
 the  chairman  of  the  workers'  compensation board, INCLUDING, BUT NOT
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.

                                                            LBD07442-01-1

 S. 4047                             2
 
 LIMITED TO, DURABLE MEDICAL EQUIPMENT OR SUPPLIES.    ADDITIONALLY,  THE
 SUPERINTENDENT,  AFTER CONSULTATION WITH THE WORKERS' COMPENSATION BOARD
 AND THE COMMISSIONER OF HEALTH, SHALL  PROMULGATE  TREATMENT  GUIDELINES
 WITH RESPECT TO TREATING COVERED PERSONS.  CHARGES FOR SERVICES THAT ARE
 NOT  SPECIFICALLY  SCHEDULED  BY  THE SUPERINTENDENT OF INSURANCE OR THE
 CHAIRMAN OF THE WORKERS' COMPENSATION  BOARD,  OR  ARE  NOT  COMPENSABLE
 CHARGES  UNDER MEDICARE ARE NOT COMPENSABLE HEALTH SERVICE CHARGES UNDER
 SUBSECTION (A) OF SECTION FIVE THOUSAND ONE HUNDRED TWO OF THIS ARTICLE.
   (c) No provider of health  services  specified  in  paragraph  one  of
 subsection  (a) of section five thousand one hundred two of this article
 may demand or request any payment in addition to the charges  authorized
 pursuant  to  this  section.  NO SUCH PROVIDER MAY BE REIMBURSED FOR ANY
 SERVICES UNLESS THE  PROVIDER  COMPLIES  WITH  SUBSECTION  (D)  OF  THIS
 SECTION.  Every  insurer  shall report to the commissioner of health any
 patterns of overcharging, excessive treatment or other improper  actions
 by a health provider within thirty days after such insurer has knowledge
 of such pattern.
   (D) NOTWITHSTANDING ANY OTHER PROVISION OF STATUTE, RULE OR REGULATION
 TO  THE CONTRARY, THE FOLLOWING SHALL APPLY FOR ALL INDIVIDUALS OR ENTI-
 TIES THAT PROVIDE, TREAT, OR CHARGE FOR SERVICES SPECIFIED IN  PARAGRAPH
 ONE  OF  SUBSECTION (A) OF SECTION FIVE THOUSAND ONE HUNDRED TWO OF THIS
 ARTICLE:
   (1) THE TREATING PROVIDER SHALL FOLLOW THE TREATMENT GUIDELINES ESTAB-
 LISHED BY THE SUPERINTENDENT;
   (2) DEVIATIONS FROM THE TREATMENT GUIDELINES MAY  BE  PERMITTED  UNDER
 THE FOLLOWING CONDITIONS:
   (I)  PRIOR WRITTEN OR ELECTRONIC REQUEST IS GIVEN TO THE INSURER PRIOR
 TO COMMENCING TREATMENT. THE REQUEST SHALL CONTAIN JUSTIFICATION FOR THE
 DEVIATION FROM THE TREATMENT  GUIDELINES.  THE  BURDEN  OF  SHOWING  THE
 NECESSITY  OF  THE  DEVIATION  REMAINS  SOLELY ON THE TREATING PROVIDER.
 FAILURE TO PROVIDE THIS REQUEST SHALL RESULT IN A MAXIMUM  REIMBURSEMENT
 OF FIFTY PERCENT OF THE TREATMENT GUIDELINES.
   (II)  THE INSURER SHALL NOT BE PRECLUDED FROM EVALUATING THE DEVIATION
 FOR PAYMENT DURING THE PENDENCY OF THE  REVIEW,  AND  MAY  UTILIZE  PEER
 REVIEW FOR EVALUATION OF THE DEVIATION.
   (III)  ANY  DISPUTES  SHALL BE RESOLVED THROUGH A PANEL OF EXPERTS WHO
 HAVE BEEN TRAINED OR CERTIFIED IN THE TREATMENT GUIDELINES  PURSUANT  TO
 SUBSECTION (E) OF SECTION FIVE THOUSAND ONE HUNDRED SIX OF THIS ARTICLE.
   (3)  AN INSURER MAY SCHEDULE AN INDEPENDENT MEDICAL EXAMINATION AT ANY
 TIME DURING THE COURSE OF TREATMENT.
   (4) SERVICES OR SUPPLIES NOT COVERED BY THE  TREATMENT  GUIDELINES  OR
 THE WORKERS' COMPENSATION FEE SCHEDULE SHALL NOT BE COMPENSABLE.
   §  2.  Section  5106  of  the insurance law is amended by adding a new
 subsection (e) to read as follows:
   (E) EVERY INSURER SHALL PROVIDE THE TREATING PROVIDER WITH THE  OPTION
 OF  SUBMITTING  A  DISPUTE  INVOLVING  A REQUEST FOR DEVIATIONS FROM THE
 TREATMENT GUIDELINES UNDER SUBSECTION (D) OF SECTION FIVE  THOUSAND  ONE
 HUNDRED  EIGHT  OF  THIS  ARTICLE  TO ARBITRATION PURSUANT TO SIMPLIFIED
 PROCEDURES PROMULGATED OR APPROVED BY THE SUPERINTENDENT.  SUCH  SIMPLI-
 FIED PROCEDURES SHALL INCLUDE ARBITRATION THROUGH A PANEL OF EXPERTS WHO
 HAVE BEEN TRAINED OR CERTIFIED IN THE TREATMENT GUIDELINES.
   §  3.  This  act  shall take effect immediately and shall apply to all
 actions and proceedings commenced on or after such date; and shall  also
 apply  to  any  action  or  proceeding which was commenced prior to such
 effective date where, as of such date, a trial of the issues has not yet
 commenced.

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Senate Bill S4047

Sponsored By

Archive: Last Bill Status - In Senate Committee Insurance Committee

Actions

co-Sponsors

2021-S4047 (ACTIVE) - Details

2021-S4047 (ACTIVE) - Summary

2021-S4047 (ACTIVE) - Sponsor Memo

2021-S4047 (ACTIVE) - Bill Text download pdf

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Sponsored By

Neil D. Breslin

Archive: Last Bill Status - In Senate Committee Insurance Committee

Actions

co-Sponsors

Jeremy Cooney

2021-S4047 (ACTIVE) - Details

2021-S4047 (ACTIVE) - Summary

2021-S4047 (ACTIVE) - Sponsor Memo

2021-S4047 (ACTIVE) - Bill Text download pdf

Comments