Relates to credentialing of certain health care providers for participation in an insurer's network for managed care products

Summary of provisions

Section 1 of the bill amends subsection (a) of Section 4803 of the insurance law by adding a new paragraph (3) that provides that newly licensed health care professionals, health care professionals that have recently relocated to the state or a physician who has changed their corporate relationship such that it results in the issuance of a new tax identification number under which their services are billed for, who are employed by a licensed Article 28 facility whose other employed health care professionals participate in the in-network portion of a health plan's network shall be considered provisionally credentialed from the date of application.

Section 2 is the effective date

Existing law

The latest of the managed care reform laws (Chapter 237 of the Laws of 2009) provided that newly licensed health care professionals or health care professionals that recently relocated to New York State who joined a group practice of health care professionals and have applied to be credentialed as part of the in-network of a health plan's network are considered provisionally credentialed if their application is not approved or denied with 90 days from the date of application.

Justification

The model of care delivery is gradually shifting from a physician private practice model to a model of hospital or health system employed physicians. In order to recruit and retain physicians and physician extenders, upstate hospitals in a market of increasing physician shortage have been forced to be at the forefront of this shifting model of care. However, faced with increasingly constrained revenue from Medicare and Medicaid cuts and commercial health plans, hospitals, who most often lose money on physicians services component of care even with full payment, cannot carry afford to can-y a physician on salary for 90 days without reimbursement for their services nor based on the physician shortage can they afford to be without the services of these physicians.

Hospitals as licensed and regulated Article 28 facilities are statutorily required to credential any provider before extending

admitting privileges or allowing the professional to provide care within the facility. According to both hospitals and health plan administrators it is almost unheard of for a hospital itself to employ any physician who would be unsuitable for health plan credentialing.

Furthermore, should this rare circumstance actually occur, hospitals most often have a longstanding contractual relationships with the principal health plans in their service areas and there exists an adequate flow of payments between the health plans and the hospital, to allow the health plan to recoup any payments made to the hospitals for the services provided by any health professional that is ultimately not credentialed as is provided for in the legislation.

Legislative history

New Bill.

Fiscal implications

None

Local fiscal implications

None.

Effective date

This bill is effective ninety days after which it shall have become law, and applies to applications submitted after that date, and shall not apply submitted prior to such date if such application is resubmitted in substantially similar form on or after the date on which this act shall have become law.