STATE OF NEW YORK ________________________________________________________________________ 5827 2019-2020 Regular Sessions IN ASSEMBLY February 19, 2019 ___________ Introduced by M. of A. TITUS, STECK -- read once and referred to the Committee on Insurance AN ACT to amend the public health law and the insurance law, in relation to utilization review agents The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Section 206 of the public health law is amended by adding 2 two new subdivisions 31 and 32 to read as follows: 3 31. The commissioner is hereby directed to establish and periodically 4 update from available applicants an independent pool of physicians and 5 professional health service providers in each medical and professional 6 health service specialty to serve as independent utilization review 7 agents as defined by subdivision nine of section forty-nine hundred of 8 this chapter. 9 32. (a) The commissioner shall assign physicians or other professional 10 health service providers authorized to examine or evaluate injury or 11 illness from the pool in the appropriate medical or professional health 12 service specialty and who practices in the same area or region to 13 conduct physical examinations and review medical records of covered 14 persons exclusively on a random, rotating basis to eliminate bias or 15 preference in the selection of the independent utilization review 16 agents, or alternatively, the commissioner may select a not-for-profit 17 organization to assign providers from the pool on the same basis. Such 18 assignment may be done through a process whereby a list of randomly 19 selected, appropriate medical or professional health service providers 20 is compiled by geographic region throughout the state and provided to 21 the insurance carrier and the claimant for the purposes of providing 22 both parties equal opportunity to strike an equal number of names off 23 such list until one utilization review agent remains to conduct the 24 medical examination or review of medical records. EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD05872-01-9

A. 5827 2 1 (b) When a utilization review agent is selected from the pool of qual- 2 ified utilization review agents maintained by the department, the 3 commissioner shall remove such utilization review agent's name from the 4 pool for a set period of time so that such agent shall not be available 5 for another regional utilization review agent assignment within a 6 specific duration of time as shall be determined by the commissioner. 7 The commissioner shall adjust the duration of time during which a name 8 must be withheld from the pool as necessary to balance the need to 9 reduce overutilization of certain independent utilization review agents 10 with the need to ensure that an adequate pool of independent utilization 11 review agents is available in each region or geographic area. 12 § 2. Subdivision 2 of section 4902 of the public health law, as added 13 by chapter 705 of the laws of 1996, is amended to read as follows: 14 2. Each utilization review agent shall assure adherence to the 15 requirements stated in subdivision one of this section by all contrac- 16 tors, subcontractors, subvendors, agents and employees affiliated by 17 contract or otherwise with such utilization review agent, and shall 18 conduct all reviews in an objective and impartial manner. 19 § 3. Subsection (b) of section 4902 of the insurance law, as added by 20 chapter 705 of the laws of 1996, is amended to read as follows: 21 (b) Each utilization review agent shall assure adherence to the 22 requirements stated in subsection (a) of this section by all contrac- 23 tors, subcontractors, subvendors, agents and employees affiliated by 24 contract or otherwise with such utilization review agent, and shall 25 conduct all reviews in an objective and impartial manner. 26 § 4. Section 4902 of the insurance law is amended by adding two new 27 subsections (c) and (d) to read as follows: 28 (c) Utilization review agents may have their records randomly reviewed 29 and audited periodically by both the superintendent of financial 30 services and the commissioner of health. Such superintendent and 31 commissioner shall be authorized to conduct a random review of no more 32 than five utilization review records annually during a utilization 33 review agent's triennial registration period. If, in the opinion of such 34 superintendent and commissioner, three or more of the utilization review 35 agent's records and documentation out of the five records that may be 36 audited annually are judged to be deficient, such superintendent and 37 commissioner shall be authorized to audit additional records during such 38 registration period and shall be authorized to institute a remedial 39 program prior to the expiration of the registrant's current utilization 40 review agent registration period. If during any two consecutive annual 41 audit periods a utilization review agent's records and documentation are 42 judged to be deficient in spite of any program of remedial action 43 directed on the part of such superintendent and commissioner, they may 44 remove the utilization review agent from the pool of names available to 45 conduct utilization reviews. Once a registrant's name has been removed 46 from the pool, in order to re-register as a utilization review agent the 47 registrant shall seek authorization in accordance with this article and 48 in the same manner as a practitioner who has not previously been author- 49 ized. 50 (d) The utilization review agent shall cite, whenever and wherever 51 possible, the specific page and reference to the relevant practice 52 guideline or to the relevant peer-reviewed medical literature, scientif- 53 ic studies, abstracts, and/or standard reference compendia, that the 54 agent utilized to assist him or her in reaching a determination when 55 commenting on or making any determination adverse to the claimant's 56 ongoing or concurrent care or a retrospective review based on a review

A. 5827 3 1 of the treating provider's records or an examination of the injured 2 patient or claimant. 3 § 5. Section 4905 of the insurance law is amended by adding three new 4 subsections (p), (q), and (r) to read as follows: 5 (p) A practitioner is not eligible to perform a utilization review of 6 a claimant when the appearance of or an actual conflict of interest 7 exists. A conflict of interest shall include, but not be limited to, 8 instances where the utilization review agent or someone in their office 9 or place of employment or practice practitioner has treated or examined 10 the claimant. A conflict of interest may be presumed to exist when the 11 utilization review agent and a provider that previously treated the 12 claimant has a relationship which involves a direct or substantial 13 financial interest. 14 (q) A utilization review agent shall not become the treating provider 15 for the claimant unless authorized to do so by the commissioner of 16 health, or ordered to by an administrative law judge. 17 (r) A party may, within five business days of the appointment as a 18 utilization review agent for a particular claimant, request that the 19 utilization review agent disclose all potential conflicts of interest to 20 such commissioner of health that may result from any relationship 21 between the utilization review agent and the insurance carrier, self-in- 22 sured employer, or the claimant. A potential conflict of interest exists 23 when the utilization review agent, or someone in their immediate family, 24 receives something of material value from the insurance carrier whether 25 in the form of stock, royalties, consultantship, funding by a research 26 grant, or other payment by the insurance carrier for any additional 27 service other than the utilization review, or if the utilization review 28 agent receives more than fifty percent of his or her total earned income 29 by providing utilization reviews. Such request shall be submitted, in 30 writing, to the commissioner of health and a copy shall be sent, deliv- 31 ered, or submitted to any other parties at substantially the same time. 32 Such commissioner shall determine whether any conflict of interest is 33 sufficiently material as to require disqualification of the utilization 34 review agent from performing any utilization review under this article, 35 after prompt disclosure pursuant to this subdivision. 36 § 6. This act shall take effect immediately.

Relates to the assignment of utilization review agents

What's Happening

Why It Matters