Regulates the scope, manner and performance of review of claims by utilization review agents

1 Multi-sponsor

• Micah Kellner

BILL NUMBER:A792A

Title of bill

An act to amend the public health law and the insurance law, in relation to approvals by a utilization review agent

Purpose

To improve managed care market conduct and to prohibit inappro- priate health insurance practices

Summary of provisions

Sections 1 and 2 enhance the utilization review law;

Sections 3 and 4 ensure payment for authorized medical care;

Sections 5-10 protect providers' rights under the external appeals law;

Sections 11-12 reduce the administrative burden for emergency department visits.

Justification

New York State law establishes timeframes in which utili- zation review agents must make adverse determinations. However, the law needs to be enhanced to protect consumers and providers. The way the current statute is written, the failure of a health plan to provide timely decisions about medical necessity is not penalized. In fact, that failure accrues to the benefit of the plan as a denial. The failure to make a utilization review decision within the stated time should be deemed an approved claim and not an adverse determination.

The current External Appeal Program within the NYS Insurance Department (SID) is dysfunctional resulting in an ineffectual and underused consum- er protection statute. Currently, providers (who are in the strongest position to advocate on behalf of the patient for necessary medical care) are frequently unable to appeal adverse determinations regarding medical necessity. This is mainly because 510 has not recognized the two possible methods for a provider appeal. Specifically, SID has refused to honor designations by patients, and SID deems retrospective adverse determinations by plans to be concurrent, which therefore disqualifies the provider's external appeal review. The administrative shortcomings of the External Appeal Law must be corrected so that its use can be maximized. Providers must have a clear right to appeal adverse determi- nations particularly since providers are currently prohibited from balance billing patients for covered services that are denied by the plan.

Administrative Burden for Emergency Department (ED) Visits Commercial health plans should be required to consider certain common sense factors in applying the prudent layperson standard when determining whether the medical care provided was for emergency medical services. A utilization review agent should be required to consider the time of day and the day of the week the patient presented to the emergency department, in addi- tion to the presenting symptoms, when reviewing coverage of emergency services to treat an emergency medical condition.

Legislative history

2007-08: A.8321-B - passed Assembly; 2009: A.792 - passed Assembly.

Fiscal implications

None

Effective date

January 1, next succeeding the date on which it shall have become law.