S T A T E   O F   N E W   Y O R K
 ________________________________________________________________________
 
                                   2428
 
                        2017-2018 Regular Sessions
 
                           I N  A S S E M B L Y
 
                             January 20, 2017
                                ___________
 
 Introduced by M. of A. SEPULVEDA, MONTESANO, STECK -- 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.
   § 2. The correction law is amended by adding a new  section  140-a  to
 read as follows:
   §  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.
              

                                                            LBD07467-01-7

 A. 2428                             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.
   §  3. The social services law is amended by adding a new section 368-g
 to read as follows:
   § 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.
   § 4. This act shall take effect on the first of January next  succeed-
 ing the date on which it shall have become a law.