Assembly Bill A8172

                             
                     S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   8172
 
                        2025-2026 Regular Sessions
 
                           I N  A S S E M B L Y
 
                                May 5, 2025
                                ___________
 
 Introduced by M. of A. STIRPE -- read once and referred to the Committee
   on Insurance
 
 AN  ACT  to  amend  the insurance law, in relation to establishing time-
   frames for the payment of claims to hospitals
 
   THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
 BLY, DO ENACT AS FOLLOWS:

   Section  1.  Subsection  (a) of section 3224-a of the insurance law is
 amended by adding 7 new paragraphs 1, 2, 3, 4, 5, 6 and  7  to  read  as
 follows:
   (1) AN INSURER OR AN ORGANIZATION OR CORPORATION LICENSED OR CERTIFIED
 PURSUANT  TO ARTICLE FORTY-THREE OR FORTY-SEVEN OF THIS CHAPTER OR ARTI-
 CLE FORTY-FOUR OF THE PUBLIC HEALTH LAW  SHALL  PAY  THE  CLAIM  TO  THE
 HOSPITAL,  AS  DEFINED IN ARTICLE TWENTY-EIGHT OF THE PUBLIC HEALTH LAW,
 AT THE CONTRACTED RATE FOR THE SERVICES AND SITE OF  SERVICE  AS  BILLED
 WITHIN  THE  TIMEFRAMES SET FORTH IN THIS SUBSECTION. SUCH PAYMENT SHALL
 BE MADE REGARDLESS OF ANY SUCH PAYOR'S  MEDICAL  NECESSITY,  PAYMENT  OR
 ADMINISTRATIVE  POLICIES,  INCLUDING, BUT NOT LIMITED TO, THOSE POLICIES
 REGARDING PREAUTHORIZATION, CONCURRENT AND RETROSPECTIVE MEDICAL  NECES-
 SITY REVIEW, TIMELY FILING, AND DOCUMENTATION REQUIREMENTS.
   (2)  SUBSEQUENT TO AND CONTINGENT UPON PAYING THE CLAIM AS BILLED, THE
 PAYOR MAY, WITHIN NINETY DAYS, REQUEST  THAT  THE  HOSPITAL  SUBMIT  THE
 SPECIFIC  CLINICAL  DOCUMENTATION AVAILABLE TO THE TREATING PHYSICIAN AT
 THE TIME THE DETERMINATION WAS MADE THAT HOSPITAL  CARE  WAS  CLINICALLY
 APPROPRIATE  TO  A  JOINT COMMITTEE COMPOSED OF EQUAL NUMBERS OF MEDICAL
 DIRECTORS AND/OR DELEGATED CLINICIANS FROM THE PAYOR  AND  THE  HOSPITAL
 (THE  "JOINT  COMMITTEE")  FOR A POST PAYMENT REVIEW. THE PAYOR MAY ONLY
 REQUEST SUBMISSION OF SUCH DOCUMENTATION WHEN THERE  IS  A  GOOD  FAITH,
 REASONABLE  BASIS SUPPORTED BY SPECIFIC INFORMATION AVAILABLE FOR REVIEW
 BY THE JOINT COMMITTEE THAT THE SERVICE RENDERED BY THE HOSPITAL WAS NOT
 CLINICALLY APPROPRIATE. THE PAYOR SHALL NOT  REQUEST  DOCUMENTATION  FOR
 MORE  THAN  TEN PERCENT OF THE CLAIMS PAID SINCE THE LAST MEETING OF THE
 
  EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                       [ ] is old law to be omitted.
                                                            LBD11877-01-5
              

 A. 8172                             2
 
 JOINT COMMITTEE. IF THE JOINT COMMITTEE FINDS THAT OVER FIFTY PERCENT OF
 THE CASES FOR WHICH DOCUMENTATION WAS REQUESTED WERE BILLED  INAPPROPRI-
 ATELY,  THE  PAYOR  MAY PROSPECTIVELY INCREASE THE MAXIMUM PERCENTAGE OF
 PAID CLAIMS FOR WHICH DOCUMENTATION CAN BE REQUESTED TO FIFTEEN PERCENT.
   (3)  WITHIN  SIXTY  BUSINESS  DAYS OF RECEIVING A REQUEST FOR SPECIFIC
 CLINICAL DOCUMENTATION AVAILABLE TO THE TREATING PHYSICIAN AT  THE  TIME
 THE  DETERMINATION  WAS MADE THAT INPATIENT HOSPITAL CARE WAS CLINICALLY
 APPROPRIATE, THE HOSPITAL SHALL PROVIDE THE  CLINICAL  DOCUMENTATION  TO
 THE JOINT COMMITTEE FOR A POST PAYMENT REVIEW. THE JOINT COMMITTEE SHALL
 MEET  NOT  LESS  THAN QUARTERLY TO CONDUCT SUCH REVIEWS. THE PAYOR SHALL
 NOT REDUCE, ADJUST, AMEND OR CHANGE THE  BILLED  CLAIMS  EXCEPT  AS  SET
 FORTH IN PARAGRAPH FIVE OF THIS SUBSECTION.
   (4)  FAILURE  BY  THE  HOSPITAL  TO PROVIDE THE CLINICAL DOCUMENTATION
 NECESSARY TO CONFIRM THE MEDICAL NECESSITY OF THE HOSPITAL  SERVICES  TO
 THE  JOINT  COMMITTEE  WITHIN  THE SIXTY BUSINESS DAYS OF REQUEST BY THE
 PAYOR, AS REQUIRED BY PARAGRAPH THREE OF THIS SUBSECTION,  SHALL  RESULT
 IN  AN  AUTOMATIC  APPEAL  TO  THE  INDEPENDENT THIRD-PARTY REVIEW AGENT
 DESCRIBED IN PARAGRAPH FIVE OF THIS  SUBSECTION.  NOTHING  HEREIN  SHALL
 REQUIRE  THE  JOINT  COMMITTEE  TO BE REGISTERED AS A UTILIZATION REVIEW
 AGENT UNDER ARTICLE FORTY-NINE OF  THE  PUBLIC  HEALTH  LAW  OR  ARTICLE
 FORTY-NINE OF THIS CHAPTER.
   (5)  UPON RECEIPT OF THE DOCUMENTATION REQUESTED PURSUANT TO PARAGRAPH
 TWO OF THIS SUBSECTION, BUT NO LATER THAN THE NEXT  REGULARLY  SCHEDULED
 JOINT  COMMITTEE MEETING, THE JOINT COMMITTEE SHALL  REVIEW THE DOCUMEN-
 TATION AND MAKE A JOINT DETERMINATION, IN ACCORDANCE WITH  POLICIES  AND
 STANDARDS  MUTUALLY  AGREED  UPON  BY  THE HOSPITAL AND THE PAYOR, AS TO
 WHETHER THE HOSPITAL SERVICES WERE  MEDICALLY  NECESSARY  BASED  ON  THE
 CLINICAL  INFORMATION  AVAILABLE  TO THE TREATING PROVIDER AT THE TIME A
 PATIENT WAS SEEN AND/OR ADMITTED. THE PAYOR AND HOSPITAL  MAY  AGREE  TO
 MEET  MORE  FREQUENTLY THAN QUARTERLY SO LONG AS SUCH FREQUENCY DOES NOT
 REQUIRE THE JOINT COMMITTEE TO MEET MORE FREQUENTLY  THAN  EVERY  THIRTY
 DAYS.  IN  THE  EVENT A JOINT DETERMINATION CANNOT BE AGREED UPON BY THE
 END OF THE FIRST JOINT COMMITTEE MEETING IMMEDIATELY  FOLLOWING  RECEIPT
 OF   DOCUMENTATION     REQUESTED  PURSUANT  TO  PARAGRAPH  TWO  OF  THIS
 SUBSECTION, THE PAYOR SHALL, IN CONJUNCTION WITH THE  HOSPITAL,  JOINTLY
 FORWARD  THE  CLINICAL  DOCUMENTATION  AND  ANY OTHER INFORMATION EITHER
 PARTY DEEMS TO BE RELEVANT AND CHOOSES TO PROVIDE  WITH  REGARD  TO  THE
 DETERMINATION  OF MEDICAL NECESSITY TO A  MUTUALLY AGREED UPON INDEPEND-
 ENT THIRD-PARTY REVIEW AGENT FOR A DETERMINATION, WHICH SHALL  BE  BIND-
 ING.  IF  THE  INDEPENDENT  REVIEW  AGENT  DETERMINES  THAT THE SERVICES
 PROVIDED WERE NOT MEDICALLY NECESSARY BASED ON THE CLINICAL  INFORMATION
 AVAILABLE  TO  THE  TREATING  PROVIDER  AT THE   TIME A PATIENT WAS SEEN
 AND/OR ADMITTED, IN ACCORDANCE WITH THOSE SAME STANDARDS  CONSIDERED  BY
 THE  JOINT COMMITTEE, IN WHOLE OR IN PART, THE HOSPITAL SHALL REFUND THE
 PAYOR THE AMOUNT DETERMINED TO BE NOT MEDICALLY NECESSARY WITHIN  THIRTY
 DAYS.  IF  THE  JOINT COMMITTEE OR INDEPENDENT THIRD-PARTY REVIEW DETER-
 MINES THAT THE SERVICES WERE NOT MEDICALLY NECESSARY,  IN  WHOLE  OR  IN
 PART, THE HOSPITAL SHALL NOT BILL THE INSURED, EXCEPT FOR ANY APPLICABLE
 COPAYMENT,  COINSURANCE  OR  DEDUCTIBLE  THAT  WOULD  BE  OWED  FOR  THE
 SERVICES.
   (6) NOTHING IN THIS SUBSECTION SHALL PRECLUDE A  PAYOR  AND  A  HEALTH
 CARE  PROVIDER  FROM  AGREEING  TO  OTHER  DISPUTE RESOLUTION MECHANISMS
 PROVIDED THAT THE PAYOR REMAINS RESPONSIBLE TO PAY THE CLAIM  AS  BILLED
 BY  THE  HOSPITAL  PRIOR  TO REVIEWING SUCH CLAIM FOR MEDICAL NECESSITY.
 FURTHERMORE, WHEN A HOSPITAL AND PAYOR ARE PARTIES  TO  A  PARTICIPATING
 PROVIDER AGREEMENT APPLICABLE TO THE HOSPITAL SERVICES BEING REVIEWED BY
 A. 8172                             3
 
 THE  JOINT  COMMITTEE,  THE DEFINITION OF MEDICAL NECESSITY SET FORTH IN
 SUCH PARTICIPATING PROVIDER AGREEMENT SHALL APPLY FOR PURPOSES OF  JOINT
 COMMITTEE  AND  INDEPENDENT THIRD PARTY REVIEW; HOWEVER, SUCH DEFINITION
 OF  MEDICAL NECESSITY SHALL NOT SIMPLY REFERENCE BACK TO A PAYOR'S POLI-
 CIES, NOR SHALL IT INCLUDE SITE OF SERVICE OR COST.
   (7) NOTHING IN THIS SUBSECTION  SHALL  BE  CONSTRUED  AS  LIMITING  OR
 ABRIDGING  IN  ANY  WAY  A HEALTH CARE PROVIDER'S RIGHTS UNDER PARAGRAPH
 NINE OF SUBSECTION (I) OF SECTION THIRTY-TWO HUNDRED  SIXTEEN  OR  PARA-
 GRAPH  EIGHT OF SUBSECTION (A) OF SECTION FORTY-NINE HUNDRED TWO OF THIS
 CHAPTER WITH RESPECT TO INSURANCE COVERAGE  FOR  SERVICES  TO  TREAT  AN
 EMERGENCY CONDITION.
   §  2. This act shall take effect January 1, 2026. Effective immediate-
 ly, the addition, amendment and/or repeal  of  any  rule  or  regulation
 necessary  for  the implementation of this act on its effective date are
 authorized to be made and completed on or before such effective date.