Limits denial of coverage of additional treatment related to health care services for which pre-authorization is required and was granted

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 authorization.

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 procedure, 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, however, 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 continue 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 authorization. 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 delaying or denying necessary treatment on the sole basis that they were not specifically prior authorized.

Legislative history

New Bill FISCAL IMPLICATIONS :

None

Effective date

Ninety days after it shall become law.