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

                                 3992--A

                       2009-2010 Regular Sessions

                            I N  S E N A T E

                              April 7, 2009
                               ___________

Introduced  by  Sens.  DILAN,  DIAZ,  HASSELL-THOMPSON,  KLEIN, KRUEGER,
  MONSERRATE, MONTGOMERY, ONORATO, OPPENHEIMER -- read twice and ordered
  printed, and when printed to be committed to the Committee  on  Insur-
  ance  --  committee  discharged,  bill  amended,  ordered reprinted as
  amended and recommitted to said committee

AN ACT to amend the insurance law, in relation to rules relating to  the
  processing  of  health claims and overpayments to physicians and other
  health care providers

  THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND  ASSEM-
BLY, DO ENACT AS FOLLOWS:

  Section  1.  Section  3224-b of the insurance law, as added by chapter
551 of the laws of 2006, is amended to read as follows:
  S 3224-b. Rules relating to the processing of health claims and  over-
payments  to  physicians AND OTHER HEALTH CARE PROVIDERS. (a) Processing
of health care claims. This subsection is intended to provide uniformity
and consistency in the reporting of medical services and  procedures  as
they  relate to the processing of health care claims and is not intended
to dictate reimbursement policy.
  (1) DEFINITIONS.
  (I) For purposes of this section, a "health plan" shall be defined  as
an  insurer  that is licensed to write accident and health insurance, or
that is licensed pursuant to article forty-three of this chapter  or  is
certified pursuant to article forty-four of the public health law.
  (II)  FOR THE PURPOSES OF THIS SECTION, A "PHYSICIAN" SHALL BE DEFINED
AS A PERSON LICENSED OR OTHERWISE AUTHORIZED  TO  PRACTICE  MEDICINE  IN
THIS  STATE  PURSUANT  TO   SECTION SIXTY-FIVE HUNDRED TWENTY-TWO OF THE
EDUCATION LAW.
  (III) FOR THE PURPOSES OF THIS SECTION, A "HEALTH CARE PROVIDER" SHALL
BE DEFINED AS ANY OTHER HEALTH CARE PROFESSIONAL OTHER THAN A  PHYSICIAN
WHO,  WHERE  APPLICABLE,  POSSESSES  A  CURRENT AND VALID NON-RESTRICTED
LICENSE, CERTIFICATE OR REGISTRATION TO PRACTICE IN THIS STATE  PURSUANT

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD10072-04-9
              

S. 3992--A                          2

TO  TITLE  EIGHT  OF  THE  EDUCATION  LAW  OR,  WHERE NO PROVISION FOR A
LICENSE, CERTIFICATE OR REGISTRATION  EXISTS,  IS  CREDENTIALED  BY  THE
NATIONAL ACCREDITING BODY APPROPRIATE TO THE PROFESSION.
  (2) Subject to the provisions of paragraph three of this subsection, a
health  plan shall accept and initiate the processing of all health care
claims submitted by a physician OR OTHER HEALTH CARE  PROVIDER  pursuant
to and consistent with the current version of the American medical asso-
ciation's  current  procedural terminology (CPT) codes, reporting guide-
lines and conventions and the centers for medicare and medicaid services
healthcare common procedure coding system (HCPCS).
  (3) Nothing in this section shall preclude a health plan  from  deter-
mining  that  any  such claim is not eligible for payment, in full or in
part, based on a determination that:
  (i) the claim is not complete as defined by 11 NYCRR 217;
  (ii) the service provided is not a covered benefit under the  contract
or  agreement,  including  but not limited to, a determination that such
service is not medically necessary or is experimental or  investigation-
al;
  (iii)  the  insured  did  not  obtain a referral, pre-certification or
satisfy any other condition precedent to receive covered  benefits  from
the physician OR OTHER HEALTH CARE PROVIDER;
  (iv) the covered benefit exceeds the benefit limits of the contract or
agreement;
  (v)  the  person  is  not  eligible  for  coverage or is otherwise not
compliant with the terms and conditions of his or her contract;
  (vi) another insurer, corporation or organization is liable for all or
part of the claim; or
  (vii) the plan has a reasonable suspicion of fraud or abuse. In  addi-
tion,  nothing  in this section shall be deemed to require a health plan
to pay or reimburse a claim, in full or in part, or dictate  the  amount
of  a  claim  to be paid by a health plan to a physician OR OTHER HEALTH
CARE PROVIDER.
  (4) Every health plan shall publish on its provider website and in its
provider newsletter the name of the commercially available claims  edit-
ing  software  product that the health plan utilizes and any significant
edits, as determined by the health plan, added to  the  claims  software
product  after the effective date of this section, which are made at the
request of the health plan. The health  plan  shall  also  provide  such
information upon the written request of a physician OR OTHER HEALTH CARE
PROVIDER  who  is a participating physician OR PARTICIPATING HEALTH CARE
PROVIDER in the health plan's provider network.
  (b) Overpayments to physicians AND OTHER HEALTH CARE PROVIDERS.
  (1) Other than recovery for duplicate payments, a  health  plan  shall
provide  thirty  days written notice to physicians AND OTHER HEALTH CARE
PROVIDERS before engaging in  additional  overpayment  recovery  efforts
seeking  recovery  of  the  overpayment of claims to such physicians AND
OTHER HEALTH CARE PROVIDERS. Such notice shall state the  patient  name,
service  date,  payment  amount,  proposed  adjustment, and a reasonably
specific explanation of the proposed adjustment.
  (2) A health plan shall not initiate overpayment recovery efforts more
than twenty-four months after the original payment  was  received  by  a
physician  OR  OTHER  HEALTH CARE PROVIDER.   Provided, however, that no
such time limit shall apply to overpayment recovery efforts which are:
  (i) based on a reasonable belief of fraud or other intentional miscon-
duct, or abusive billing,

S. 3992--A                          3

  (ii) required by, or initiated at the request of, a self-insured plan,
or
  (iii) required by a state or federal government program.
  Notwithstanding the aforementioned time limitations, in the event that
a physician OR OTHER HEALTH CARE PROVIDER asserts that a health plan has
underpaid  a claim or claims, the health plan may defend or set off such
assertion of underpayment based on overpayments going back  in  time  as
far  as  the  claimed  underpayment.  For  purposes  of  this paragraph,
"abusive billing" shall be defined as a billing practice  which  results
in  the  submission of claims that are not consistent with sound fiscal,
business, or medical practices and at such  frequency  and  for  such  a
period of time as to reflect a consistent course of conduct.
  (3)  Nothing  in  this  section  shall be deemed to limit an insurer's
right to pursue recovery of overpayments  that  occurred  prior  to  the
effective date of this section where the insurer has provided the physi-
cian  OR OTHER HEALTH CARE PROVIDER with notice of such recovery efforts
prior to the effective date of this section.
  S 2. This act shall take effect January 1, 2010.