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

                                 6494--A

                            I N  S E N A T E

                            January 29, 2014
                               ___________

Introduced  by  Sen.  RANZENHOFER -- read twice and ordered printed, and
  when printed to be committed to the Committee on Crime Victims,  Crime
  and   Correction   --  committee  discharged,  bill  amended,  ordered
  reprinted as amended and recommitted to said committee

AN ACT to amend the correction law  and  the  social  services  law,  in
  relation  to  the  development and implementation of automated payment
  detection, prevention and recovery solutions  to  reduce  correctional
  healthcare  overpayments, and to require that private health insurance
  providers and Medicaid are billed for eligible  inpatient hospital and
  professional services

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

  Section  1.  Legislative  intent.  Other states have saved millions of
dollars by implementing solutions to eliminate and recover  correctional
healthcare  overpayments  and  significantly  have  reduced correctional
healthcare costs by billing private health insurance providers and Medi-
caid for eligible inpatient healthcare costs. New York  can  benefit  by
implementing  similar  measures.  It is the intent of the legislature to
implement automated payment detection, prevention and recovery solutions
to reduce correctional  healthcare  overpayments,  and  to  ensure  that
private  insurance  companies and Medicaid are billed for eligible inpa-
tient hospital and professional services.
  S 2. The correction law is amended by adding a new  section  140-a  to
read as follows:
  S  140-A.    HEALTHCARE PAYMENTS; BILLING PRIVATE HEALTH INSURANCE AND
MEDICAID. 1. UNLESS OTHERWISE STATED, THE  PROVISIONS  OF  THIS  SECTION
APPLY  TO  ALL  STATE  CORRECTIONAL  HEALTHCARE SYSTEMS AND SERVICES AND
STATE CONTRACTED MANAGED CORRECTIONAL HEALTHCARE SERVICES.
  2.  THE  DEPARTMENT  SHALL  IMPLEMENT  AUTOMATED  PAYMENT   DETECTION,
PREVENTION, AND RECOVERY PROCEDURES TO ENSURE THAT PRIVATE HEALTH INSUR-
ANCE  OR  MEDICAID IS BILLED FOR ELIGIBLE INPATIENT HOSPITAL AND PROFES-
SIONAL HEALTHCARE SERVICES.  THESE PROCEDURES MUST INCLUDE, BUT ARE  NOT
LIMITED  TO, CLINICAL CODE EDITING TECHNOLOGY TO FURTHER AUTOMATE CLAIMS
RESOLUTION AND ENHANCE COST CONTAINMENT THROUGH IMPROVED CLAIM  ACCURACY

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

                                                           LBD13172-04-4

S. 6494--A                          2

AND APPROPRIATE CODE CORRECTION. EDITS PERFORMED BY THIS TECHNOLOGY MUST
BE  APPLIED  AUTOMATICALLY  BEFORE  THE ADJUDICATION OF CLAIMS, AND THIS
TECHNOLOGY MUST IDENTIFY AND PREVENT ERRORS  AND  POTENTIAL  OVERBILLING
BASED  ON  WIDELY ACCEPTED PROTOCOLS, SUCH AS THOSE USED BY THE AMERICAN
MEDICAL ASSOCIATION AND THE CENTERS FOR MEDICARE AND MEDICAID SERVICES.
  3. THE DEPARTMENT SHALL IMPLEMENT CORRECTIONAL HEALTHCARE CLAIMS AUDIT
AND RECOVERY PROCEDURES  TO  IDENTIFY  IMPROPER  PAYMENTS  MADE  DUE  TO
NON-FRAUDULENT  ISSUES. PROCEDURES THAT MUST BE IMPLEMENTED INCLUDE, BUT
ARE NOT LIMITED TO, OBTAINING PROVIDER SIGN-OFF  ON  AUDIT  RESULTS  AND
CONDUCTING  POST PAYMENT REVIEWS TO ENSURE THAT THE DIAGNOSES AND PROCE-
DURE CODES ARE ACCURATE AND VALID BASED ON SUPPORTING PHYSICIAN DOCUMEN-
TATION WITHIN THE  MEDICAL  RECORDS.  CORE  CATEGORIES  OF  REVIEWS  MAY
INCLUDE,  BUT  ARE  NOT  LIMITED TO, CODING COMPLIANCE DIAGNOSIS RELATED
GROUP (DRG) REVIEWS,  TRANSFERS,  READMISSIONS,  COST  OUTLIER  REVIEWS,
OUTPATIENT SEVENTY-TWO-HOUR RULE REVIEWS, PAYMENT ERRORS, AND BILLING.
  4. THE DEPARTMENT MAY CONTRACT TO HAVE SERVICES PERFORMED TO CARRY OUT
THE  REQUIREMENTS  OF  THIS  SECTION,  AND  THE SAVINGS GENERATED BY THE
PERFORMANCE OF THESE SERVICES MUST BE USED FOR THE OPERATION AND  ADMIN-
ISTRATION  OF  THIS  SECTION, INCLUDING SECURING THE TECHNOLOGY SERVICES
REQUIRED BY THIS SECTION. TO FURTHER ACHIEVE THESE  SAVINGS,  CONTRACTOR
REIMBURSEMENT  MAY  BE  BASED  UPON  A PERCENTAGE OF AN ACHIEVED SAVINGS
MODEL, A PER BENEFICIARY PER MONTH MODEL, A  PER  TRANSACTION  MODEL,  A
CASE-RATE   MODEL,  OR  ANY  COMBINATION  OF  THESE  MODELS.  CONTRACTOR
REIMBURSEMENT MODELS ALSO MAY  INCLUDE  PERFORMANCE  GUARANTEES  OF  THE
CONTRACTOR TO ENSURE SAVINGS IDENTIFIED EXCEED PROGRAM COSTS.
  S  3. The social services law is amended by adding a new section 368-g
to read as follows:
  S 368-G. REIMBURSEMENT OF COSTS FOR CORRECTIONAL  HEALTHCARE.    AFTER
THE AMOUNT OF FEDERAL FUNDS, IF ANY, HAVE BEEN DEDUCTED FROM THE COST OF
CORRECTIONAL  HEALTHCARE,  THE  REMAINING AMOUNT SHALL BE PAID WHOLLY BY
THE STATE.
  S 4. This act shall take effect on the first of January next  succeed-
ing the date on which it shall have become a law.