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

                                  2799

                       2015-2016 Regular Sessions

                          I N  A S S E M B L Y

                            January 20, 2015
                               ___________

Introduced  by M. of A. SEPULVEDA, MONTESANO, STECK, TENNEY, ROBINSON --
  Multi-Sponsored by -- M. of A. MAGEE, PERRY, RIVERA -- read  once  and
  referred to the Committee on Correction

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

 EXPLANATION--Matter in ITALICS (underscored) is new; matter in brackets
                      [ ] is old law to be omitted.
                                                           LBD02105-01-5
              

A. 2799                             2

LIMITED TO, CLINICAL CODE EDITING TECHNOLOGY TO FURTHER AUTOMATE  CLAIMS
RESOLUTION  AND ENHANCE COST CONTAINMENT THROUGH IMPROVED CLAIM ACCURACY
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.