What's happening
This bill requires health plans to follow specific procedures and allow appeals when using extrapolation to determine provider overpayments.
Why it matters
Increases transparency and fairness for healthcare providers. By requiring health plans to give written notice and explain the statistical methods used for extrapolation, providers are better informed and can more effectively contest overpayment determinations.
Ensures use of valid and fair audit methods. The bill mandates that health plans use stratified random sampling and valid statistical techniques, reducing the risk of arbitrary or biased audit results that could otherwise unfairly penalize providers.
Provides a clear process for appealing audit findings. Providers are guaranteed 60 business days to appeal and, if needed, can request an independent third-party review of the extrapolated findings, reducing power imbalances and supporting due process.
Shares costs of independent audit reviews. By splitting the cost of third-party audits between the provider and health plan, the bill encourages both parties to seek fair resolution rather than relying on potentially one-sided internal processes.
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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
2842
2019-2020 Regular Sessions
IN ASSEMBLY
January 25, 2019
Introduced by M. of A. LAVINE, GOTTFRIED, COOK, ABINANTI, ARROYO, RIVERA -- 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.
LBD04607-01-9
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.