What's happening
This bill prohibits health plans from using extrapolation to determine overpayments or threatening sanctions against providers who challenge overpayments, except in cases of suspected fraud or intentional misconduct.
Why it matters
Protects health care providers from potentially unfair recoupment practices. by restricting health plans from using extrapolation—a method that estimates overpayment amounts based on a sample of claims—unless there is evidence of fraud or intentional wrongdoing. This means providers are less likely to face large, retroactive financial demands based on statistical assumptions.
Reduces the risk of retaliation against providers. who dispute or appeal overpayment claims, as health plans are explicitly barred from threatening disciplinary sanctions or making reports to professional boards, unless fraud or intentional misconduct is suspected. This encourages providers to challenge questionable payment recoveries without fear of punitive consequences.
Imposes significant financial penalties on health plans. (a $50,000 fine per violation) that violate these new protections, creating a strong deterrent against improper use of extrapolation or intimidation tactics and giving providers a clear recourse if their rights are infringed.
May lead to fairer and more transparent audits and payment dispute processes. between insurers and health care providers, potentially improving provider-insurer relationships and ensuring that error corrections are handled on an individual claim basis rather than through broad statistical estimates.
Albany, before your first meeting.
Every bill that moved yesterday, summarized in a sentence and ranked by impact. The Albany Scorecard follows on Sundays.
Free. Unsubscribe in one click. Want alerts on specific bills? Create an account.
Who cares
Headline styles
Protect Providers From Insurer Threats
Plain English, a few words. Used as the page title.
Sponsors
1 Co-sponsor
History
- Referred to insurance
- Referred to insurance
Companion bill
The same bill in the other chamber. A bill becomes law when one version passes both houses and the governor signs it, so either number can carry it.
Protect Doctors From Insurers
In Assembly Committee · Insurance · Sponsor Richard Gottfried
Full text
1 pageUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
873
2019-2020 Regular Sessions
IN SENATE
January 9, 2019
Introduced by Sens. RIVERA, SEPULVEDA -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance
AN ACT to amend the insurance law, in relation to insurer recovery from health care providers
The People of the State of New York, represented in Senate and Assembly, do enact as follows:
Section 1. Subsection (b) of section 3224-b of the insurance law is amended by adding two new paragraphs 6 and 7 to read as follows:
(6) A health plan shall not determine an overpayment amount through the use of extrapolation except with the consent of the health care provider, except where there is a reasonable belief of fraud or intentional misconduct.
(7) A health care plan may not threaten to sanction a health care provider including a report to a relevant disciplinary body as a result of a health care provider challenging an alleged overpayment except where there is a reasonable belief of fraud or intentional misconduct. A health care plan found to have violated this paragraph shall be subject to a fine of fifty thousand dollars per violation.
§ 2. This act shall take effect immediately.
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD03433-01-9
Reflowed for reading: line numbers and page breaks removed. Cite the official text.
Sponsor's memo
Title of bill
An act to amend the insurance law, in relation to insurer recovery from health care providers
Purpose or general idea of bill
To enable fair and equitable resolution of allegations by insurers that a health care professional has been overpaid for a benefit claim.
Summary of specific provisions
The bill would amend section 3224-b of the insurance law to prohibit the use of extrapolation to determine amounts overpaid except in instances where there is a reasonable belief of fraud or intentional misconduct, to prohibit threats of retribution against health care professionals who challenge allegations of overpayment, and to require health plans to initiate overpayment proceedings within 12 months (instead of the current 24) of the payment.
Justification
In some instances, health plans use the practice of extrapolation of a relatively few claims to determine overpayment amounts that can stretch into tens of thousands, and perhaps even hundreds of thousands, of dollars. Contesting a refund demand is difficult, and results in extraordinary legal and other expert costs. As a result, health care providers are often intimidated into settling the dispute. It can be burdensome and harassing to require a physician to defend bills submit- ted and paid two years back. Health plans should act expeditiously if they have reasonable demands for recouping overpayments.
Prior legislative history
2013-2014: S6445 2015-2016: S720 2017-2018: S1101
Fiscal implications
None.
Effective date
Immediately.
Summaries, headlines and scores are AI-generated from the official bill text. How we score bills. Source: NYS Open Legislation.