What's happening
This bill requires health plans to follow specific procedures and provide notice when using extrapolation to determine provider overpayments.
Why it matters
Establishes new transparency requirements. Health plans must now provide written notice to providers before using extrapolation, ensuring providers aren’t surprised by this statistical method that can significantly increase the amount of alleged overpayment.
Mandates fairer audit procedures. The bill requires health plans to use valid, stratified random sampling methods in extrapolation audits, which can help prevent biased or unrepresentative samples that might unfairly penalize providers.
Strengthens provider appeal rights. Providers are given 60 business days to appeal audit findings—much longer than many standard appeal windows—giving them more time to gather evidence and respond.
Creates a neutral review process. If there’s a dispute after an appeal, providers and health plans must agree on an independent third-party auditor, with costs shared equally, adding a layer of impartiality and potentially reducing adversarial conflict.
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Who cares
Headline styles
Protect Health Provider Audits
Plain English, a few words. Used as the page title.
Sponsors
1 Multi-sponsor
History
- Referred to insurance
- Referred to insurance
Full text
1 pageUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
7920
2017-2018 Regular Sessions
IN ASSEMBLY
May 19, 2017
Introduced by M. of A. LAVINE, GOTTFRIED, COOK, ABINANTI, ARROYO, RIVERA, McKEVITT -- Multi-Sponsored by -- M. of A. PERRY -- read once and referred to the Committee on Insurance
AN ACT to amend the insurance law, in relation to determination of overpayments to health care providers by extrapolation
The People of the State of New York, represented in Senate and Assembly, do enact as follows:
Section 1. Paragraph 2 of subsection (b) of section 3224-b of the insurance law, as amended by chapter 237 of the laws of 2009, is amended to read as follows:
(2) A health plan shall provide a health care provider with the opportunity to challenge an overpayment recovery, including the sharing of claims information, and shall establish written policies and procedures for health care providers to follow to challenge an overpayment recovery. Such challenge shall set forth the specific grounds on which the provider is challenging the overpayment recovery. In the event that the process known as extrapolation will be used in determining whether health care providers have received overpayments from a health care plan, the health care plan shall comply with the following requirements:
(A) advise the health care provider with written notice that extrapolation will be utilized;
(B) apply a valid statistical methodology that uses stratified random sampling methods to assure a fair evaluation of the claims subject to audit;
(C) advise the health care provider as to the type of methodology used;
(D) provide the health care provider sixty business days to appeal the audit findings; and
(E) in the event of an appeal of the audit findings, the health care provider may seek a review of the findings by a mutually agreed upon independent third party auditor. The cost of a third party review shall be shared equally between the parties.
§ 2. This act shall take effect immediately.
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD11795-01-7
Reflowed for reading: line numbers and page breaks removed. Cite the official text.
Summaries, headlines and scores are AI-generated from the official bill text. How we score bills. Source: NYS Open Legislation.