S T A T E   O F   N E W   Y O R K
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                                  6189

                       2009-2010 Regular Sessions

                            I N  S E N A T E

                           September 25, 2009
                               ___________

Introduced  by  Sen.  KLEIN  -- read twice and ordered printed, and when
  printed to be committed to the Committee on Rules

AN ACT to amend the insurance law, in relation to  overpayment  recovery
  efforts initiated by insurers and HMOs

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

  Section 1. 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:
  (b) Overpayments to health care providers. (1) Other than recovery for
duplicate payments, a health plan  shall  provide  thirty  days  written
notice  to  health care providers before engaging in additional overpay-
ment recovery efforts seeking recovery of the overpayment of  claims  to
such  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 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.
  (3) A health plan shall not initiate overpayment recovery efforts more
than  twenty-four  months  after  the original payment was received by a
health care provider. However, no such time limit shall apply  to  over-
payment  recovery  efforts that are: (i) based on a reasonable belief of
fraud or  other  intentional  misconduct,  [or  abusive  billing,]  (ii)
required  by,  or  initiated  at the request of, a self-insured plan, or
(iii) required or authorized by a state or federal government program or
coverage that is provided by this state or a municipality thereof to its
respective employees, retirees or members. Notwithstanding the aforemen-

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD14660-02-9
              

S. 6189                             2

tioned time limitations, in  the  event  that  a  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 over-
payments  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.]
  (4)  For the purposes of this subsection the term "health care provid-
er" shall mean an entity licensed or certified pursuant to article twen-
ty-eight, thirty-six or forty of  the  public  health  law,  a  facility
licensed  pursuant  to article nineteen, thirty-one or thirty-two of the
mental hygiene law, or a health care professional  licensed,  registered
or certified pursuant to title eight of the education law.
  (5)  Nothing  in this section shall be deemed to limit a health plan's
right to pursue recovery of overpayments  that  occurred  prior  to  the
effective  date  of  this section where the health plan has provided the
health care provider with notice of such recovery efforts prior  to  the
effective date of this section.
  (6)  NOTHING  IN  THIS  SECTION SHALL APPLY TO ANY TITLE XIX FEDERALLY
AUTHORIZED MEDICAID PROGRAMS.
  S 2. This act shall take effect on the one hundred twentieth day after
it shall have become a law; provided, however, that  if  section  10  of
chapter 237 of the laws of 2009 shall not have taken effect on or before
such  date  then  section  one of this act shall take effect on the same
date and in the same manner as section 10 of such chapter takes effect.