Attention NYS Council Hospital Members
January 21, 2020
From Article VII Memo of Support / Health and Mental Hygiene Budget Bill
NYS Council hospital-based members,
The legislation described below would make significant consumer-friendly changes and lift certain regulatory requirements that stand in the way of efficient decision-making impacting client care.
Part J – Health Related Consumer Protections Purpose:
This bill would make statutory changes to the Insurance, Public Health and Financial Services Laws to eliminate administrative denials for medically necessary services and promote efficiencies; reduce friction between payers and certain providers and achieve new levels of cooperation between payers (including commercial insurers and managed care organizations) and general hospitals or other providers of health care services.
Summary of Provisions and Statement in Support:
Section one of this bill would amend section 3217-b of the insurance law to add requirements for when an insurer may deny payment to a general hospital for medically necessary inpatient, observation, and emergency department services.
Section two of this bill would amend section 4325 of the insurance law to add requirements for when an insurer may deny payment to a general hospital for medically necessary inpatient, observation, and emergency department services.
Section three of this bill would amend section 4406-c of the public health law to add requirements for when an insurer may deny payment to a general hospital for medically necessary inpatient, observation, and emergency department services.
Section four of this bill would amend section 3224-a of the insurance law to require payers to provide product information to providers when the insurer requests documentation for payment purposes and subsequently requires payment of any due claims within 15 days or require payment of interest.
Section five of this bill would amend 3224-a of the insurance law to clarify that when payers seek to down-code claims submitted by providers, those down-coding decisions should be based on national coding guidelines accepted by the Centers for Medicare & Medicaid Services (CMS) and/or the American Medical Association (AMA), and increases the period over which a payer is required to pay interest if claims payment are not timely.
Section six of this bill would amend section 3224-a of the insurance law to require the Department of Financial Services in consultation with the Department of Health to convene a health care administrative work group to study and evaluate mechanisms to reduce health care administration costs and complexities.
Section seven of this bill would amend the insurance law by adding a new section 345 that requires plans to report to the Department of Financial Services quarterly and annually on health care claims payment performance.
Section eight of this bill would amend section 4903 of the public health law to shorten the timeframe to one business day for utilization review agents to make prior authorization determinations for inpatient rehabilitation services provided by a hospital or skilled nursing facilities.
Section nine of this bill would amend section 4903 of the insurance law to shorten the timeframe to one business day for utilization review agents to make prior authorization determinations for inpatient rehabilitation services provided by a hospital of skilled nursing facilities.
Sections ten and eleven of this bill would amend section 4904 of the public health law and section 4904 of the insurance law, respectively, to shorten the timeframe for making appeal determinations from 60 days to 30 days.
Section twelve of this bill would amend section 4803 of the insurance law to require payers to provisionally credential physicians to permit these physicians to provide services to plan members while they undergo the full plan credentialing process.
Section thirteen of this bill would amend section 4406-d of the public health law to require payers to provisionally credential physicians to permit these physicians to provide services to plan members, while they undergo the full plan credentialing process.
Sections fourteen and fifteen of this bill would amend section 605 to of the financial services law to expand the independent dispute resolution process to include inpatient services following an emergency room visit.
Section sixteen of this bill would amend section 605 of the financial services law to expand the independent dispute resolution process to all hospitals.
Section seventeen of this bill would amend section 606 of the financial services law to require payers to hold consumers harmless and pay out of network providers directly for emergency services, including any inpatient services furnished by a hospital that follow an emergency room visit, and prohibit providers from billing patients for those services, other than any applicable cost sharing.
Section eighteen of this bill would amend the civil practice law to add a new section 213-d to shorten the time frame to bring an action to collect medical debt from six years to three years.
Section nineteen of this bill would establish the effective date for this bill.
Budget Implications: Enactment of this bill is necessary to implement the FY2021 Executive Budget.
Effective Date: This bill would take effect for services provided on or after January 1, 2021, with the exception of the provisions on provisional credentialing and out of network services, which will go into effect as of July 1, 2020.