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A09946 Summary:

A09946 Actions:

A09946 Floor Votes:

A09946 Text:

 
                STATE OF NEW YORK
        ________________________________________________________________________
 
                                         9946--B
 
                   IN ASSEMBLY
 
                                     April 26, 2012
                                       ___________
 
        Introduced  by  M.  of  A. MORELLE, P. RIVERA, ABINANTI -- read once and
          referred to the Committee on Insurance -- reported and referred to the
          Committee on Ways and Means --  committee  discharged,  bill  amended,
          ordered  reprinted  as  amended  and  recommitted to said committee --
          again reported from said committee with amendments, ordered  reprinted
          as amended and recommitted to said committee
 

        AN ACT to amend the insurance law and the public health law, in relation
          to denial of claims
 
          The  People of the State of New York, represented in Senate and Assem-
        bly, do enact as follows:
 
     1    Section 1.  Section 3217-b of the insurance law is amended by adding a
     2  new subsection (j) to read as follows:
     3    (j) (1) An insurer shall not deny payment to a general hospital certi-
     4  fied pursuant to article twenty-eight of the public  health  law  for  a
     5  claim for medically necessary inpatient services resulting from an emer-
     6  gency  admission provided by a general hospital solely on the basis that
     7  the general hospital  did  not  timely  notify  such  insurer  that  the
     8  services had been provided.

     9    (2)  Nothing  in this subsection shall preclude a general hospital and
    10  an insurer from agreeing to requirements for  timely  notification  that
    11  medically  necessary  inpatient  services  resulting  from  an emergency
    12  admission have been provided and to reductions in payment for failure to
    13  timely notify; provided, however that: (i) any  requirement  for  timely
    14  notification  must  provide for a reasonable extension of timeframes for
    15  notification for emergency services  provided  on  weekends  or  federal
    16  holidays,  (ii) any agreed to reduction in payment for failure to timely
    17  notify shall not exceed the lesser of two  thousand  dollars  or  twelve
    18  percent  of  the payment amount otherwise due for the services provided,

    19  and (iii) any agreed to reduction in payment for failure to timely noti-
    20  fy shall not be imposed if the patient's insurance coverage could not be
    21  determined by the hospital after reasonable  efforts  at  the  time  the
    22  inpatient services were provided.
    23    §  2.  Section  4325  of  the insurance law is amended by adding a new
    24  subsection (k) to read as follows:
 
         EXPLANATION--Matter in italics (underscored) is new; matter in brackets
                              [ ] is old law to be omitted.
                                                                   LBD15258-06-2
        A. 9946--B                          2
 
     1    (k) (1) A corporation organized under  this  article  shall  not  deny
     2  payment to a general hospital certified pursuant to article twenty-eight

     3  of  the  public health law for a claim for medically necessary inpatient
     4  services resulting from an emergency admission  provided  by  a  general
     5  hospital  solely  on  the basis that the general hospital did not timely
     6  notify such insurer that the services had been provided.
     7    (2) Nothing in this subsection shall preclude a general hospital and a
     8  corporation from agreeing to requirements for timely  notification  that
     9  medically  necessary  inpatient  services  resulting  from  an emergency
    10  admission have been provided and to reductions in payment for failure to
    11  timely notify; provided, however that: (i) any  requirement  for  timely
    12  notification  must  provide for a reasonable extension of timeframes for

    13  notification for emergency services  provided  on  weekends  or  federal
    14  holidays,  (ii) any agreed to reduction in payment for failure to timely
    15  notify shall not exceed the lesser of two  thousand  dollars  or  twelve
    16  percent  of  the payment amount otherwise due for the services provided,
    17  and (iii) any agreed to reduction in payment shall not be imposed if the
    18  patient's insurance coverage could not be  determined  by  the  hospital
    19  after  reasonable  efforts  at  the  time  the  inpatient  services were
    20  provided.
    21    § 3. Section 4406-c of the public health law is amended  by  adding  a
    22  new subdivision 8 to read as follows:
    23    8. (a) A health care plan shall not deny payment to a general hospital

    24  certified  pursuant  to article twenty-eight of this chapter for a claim
    25  for medically necessary inpatient services resulting from  an  emergency
    26  admission  provided  by  a general hospital solely on the basis that the
    27  general hospital did not timely notify such health care  plan  that  the
    28  services had been provided.
    29    (b)  Nothing in this subdivision shall preclude a general hospital and
    30  a health care plan from agreeing to requirements for timely notification
    31  that medically necessary inpatient services resulting from an  emergency
    32  admission have been provided and to reductions in payment for failure to
    33  timely  notify;  provided,  however that: (i) any requirement for timely
    34  notification must provide for a reasonable extension of  timeframes  for

    35  notification  for  emergency  services  provided  on weekends or federal
    36  holidays, (ii) any agreed to reduction in payment for failure to  timely
    37  notify  shall  not  exceed  the lesser of two thousand dollars or twelve
    38  percent of the payment amount otherwise due for  the  service  provided,
    39  and (iii) any agreed to reduction in payment shall not be imposed if the
    40  patient's coverage could not be determined by the hospital after reason-
    41  able efforts at the time the inpatient services were provided.
    42    §  4.  Section  3224-a of the insurance law is amended by adding a new
    43  subsection (i) to read as follows:
    44    (i) Except where the parties have developed  a  mutually  agreed  upon
    45  process for the reconciliation of coding disputes that includes a review

    46  of  submitted  medical  records  to  ascertain  the  correct  coding for
    47  payment, a general hospital certified pursuant to  article  twenty-eight
    48  of  the  public health law shall, upon receipt of payment of a claim for
    49  which payment has been adjusted  based  on  a  particular  coding  to  a
    50  patient  including  the  assignment of diagnosis and procedure, have the
    51  opportunity to submit the affected claim with medical records supporting
    52  the hospital's initial coding of the claim within thirty days of receipt
    53  of payment.  Upon receipt of such medical  records,  an  insurer  or  an
    54  organization  or  corporation  licensed or certified pursuant to article
    55  forty-three or forty-seven of this chapter or article forty-four of  the

    56  public health law shall review such information to ascertain the correct
        A. 9946--B                          3
 
     1  coding  for  payment  and process the claim in accordance with the time-
     2  frames set forth in subsection (a) of this section.  In  the  event  the
     3  insurer,  organization,  or  corporation  processes the claim consistent
     4  with  its initial determination, such decision shall be accompanied by a
     5  statement of the insurer, organization or corporation setting forth  the
     6  specific  reasons why the initial adjustment was appropriate.  An insur-
     7  er, organization, or corporation that increases the payment based on the
     8  information submitted by the general hospital, but fails  to  do  so  in

     9  accordance  with  the  timeframes  set  forth  in subsection (a) of this
    10  section, shall pay to the general hospital interest  on  the  amount  of
    11  such  increase  at  the  rate  set  by  the commissioner of taxation and
    12  finance for corporate taxes pursuant to paragraph one of subdivision (e)
    13  of section one thousand ninety-six of the tax law, to be  computed  from
    14  the  end  of  the  forty-five day period after resubmission of the addi-
    15  tional medical record information. Provided, however, a failure to remit
    16  timely payment shall not constitute a violation of this section. Neither
    17  the initial or subsequent processing of the claim by the insurer, organ-
    18  ization, or corporation shall be  deemed  an  adverse  determination  as

    19  defined  in  section four thousand nine hundred of this chapter if based
    20  solely on a coding determination. Nothing in this subsection shall apply
    21  to those instances in which the insurer or organization, or  corporation
    22  has a reasonable suspicion of fraud or abuse.
    23    § 5. This act shall take effect July 1, 2013.