BILL NUMBER: S1394

SPONSOR: RIVERA
 
TITLE OF BILL:

An act to amend the insurance law, in relation to denial of coverage of
treatment related to health care services for which pre-authorization
was granted

 
PURPOSE:

To expand the current prior authorization exception for surgical and
invasive procedures to include concurrent symptoms and side effects.

 
SUMMARY OF PROVISIONS:

Section 1 of the bill adds a new subsection (c-1) of section 3238 of the
Insurance Law to include concurrent symptoms and side effects to the
types of conditions that cannot be denied for lack of prior authori-
zation.

              

Section two provides that this act shall take effect 90 days after
enactment.

 
JUSTIFICATION:

In 2007, Chapter 451 was signed into law and required plans to reimburse
providers when the plan had already provided prior authorization for the
care. Importantly, this law also limits when a plan is entitled to deny
payment for surgical or invasive procedures that are closely related and
rendered at the same time as the services that had been explicitly prior
authorized. This flexibility was added to ensure that when a provider
encountered an unexpected complication or need during a surgical proce-
dure, it was not medically prudent to leave an individuals health need
unaddressed during the time it took for the health plan to be contacted
and issue a separate prior authorization. The law still reserves the
plan's right to make a medical necessity determination and simply bars
from the plan from issuing an administrative denial over the deviation
from the initial authorization.

Recently, certain vendor organizations subcontracted by health plans
regulated by New York have been denying related services when they are
not clearly pre-authorized although services do not meet the current
definition of "surgical or invasive, requiring sedation".  These carve-
out entities are denying reimbursement for medically sensitive services,
even when medically necessary, if not explicitly prior authorized. For
example, chemotherapy is prior authorized on an outpatient basis, howev-
er, patients who arrive for chemotherapy are often treated for related
symptoms such as nausea, low platelet count, allergic reactions, etc.
These symptoms are treated by the provider so the individual can contin-
ue to receive chemotherapy, especially because patients are maintaining
strict regimens to fight their particular type of cancer and/or have
traveled long distances to a hospital that provides oncology services.

Similar to the surgical/invasive procedure exception that was initially
inserted to the prior authorization law, it is not in the patient's
medical interest to leave symptoms unaddressed or delay chemotherapy so
the health plan can be contacted to issue a separate prior authori-
zation. This bill would expand this current exception to ensure patients
receive medically necessary services when they are in a medically
compromised state and prevent plans or their subcontractors from delay-
ing or denying necessary treatment on the sole basis that they were not
specifically prior authorized.

 
LEGISLATIVE HISTORY:

2016: S.7558
2017: S.3565

 
FISCAL IMPLICATIONS:

None

 
EFFECTIVE DATE:
Ninety days after it shall become law.