Health Insurance in New York

1. Health Insurance in New York Laura Dillon, Principal Examiner New York Insurance Department Consumer Services Bureau One Commerce Plaza Albany NY 12257 (518) 486-9105 Ldillon@ins.state.ny.us

2. New York Insurance Department Is an Administrative Agency We have Jurisdiction over policies issued for delivery in New York Can’t assist with: Self-funded plans Medicare, including Medicare Advantage Out of State contracts Federal Employee plans Most contractual issues

3. New York Insurance Department Consumer Services Bureau Investigate complaints against all Department licensees Insurers, HMOs, Agents, Brokers, Adjusters, Service Contract Providers Oversee the External Appeal process

4. Health Insurance in New York NY Insurance Law requires insurers and HMOs to provide specific mandated benefits Such as maternity care, 2nd opinion for cancer diagnosis, screening for certain cancers, well child care, diabetic supplies, infertility and certain screening tests. Coverage is subject to Utilization Review (Medical Necessity) where appropriate.

5. Health Insurance in New York Prompt Pay Law Claims must be processed within specific time frames after receipt by the insurer/HMO Claims must be paid: Within 45 days if submitted on paper, or Within 30 days if submitted via electronic means, or Denied within 30 days of receipt, or Request additional information within 30 days of receipt. Request must be in writing and must include all necessary information

6. Health Insurance in New York Prompt Pay Law (cont.) Clean Claim (obligation to pay must be reasonably clear) Regulation 178 (paper claims) Fraudulent claims Reasonable basis to suspect fraud Don’t have to comply with time frames

7. Health Insurance in New York Prompt Pay Law (cont.) Interest 12% simple interest Begins to accrue the day the claim payment is due Not applicable to PIP payments or deductibles Is applicable to adjusted claims, if health plan made an error (amount of additional payment)

8. Health Insurance in New York Prompt Pay Monetary Penalties Each late claim is a separate violation 1st time Department can fine for individual violations Based on closed complaints Collected over $10 million in fines since law became effective

9. Health Insurance in New York External Appeal Review by a neutral medical professional for denials based on lack of medical necessity or experimental/investigational services. Must request one level of internal appeal after initial denial. Must file external appeal application within 45 days of FAD. Decision is binding on insurer/HMO. Member/patient is always permitted to appeal. Providers can appeal retrospective and concurrent denials.

10. Health Insurance in New York Recent change to External Appeal include: Right for providers to appeal concurrent denials. Loser pays. Hold harmless provision. Department has the right to confirm the designee.

11. v Contractual Issues Provider responsibilities (participating) Know contractual requirements Time frames approval/pre-certification requirements Know applicable laws Sections 3217-b and 4325 of the New York Insurance Law Post Payments timely Make applicable adjustments to patient account

12. Health Insurance in New York Contractual Issues (cont.) Beware of requesting special handling for certain types of services. Technology limits can cause problems with the processing of these claims.

13. Managed Care Reform Act of 2009 Timely Filing of Claims 120 days after date of service for claims submitted by providers and subscribers. Contract with provider may provide more time but cannot be less than 120 days. Medicaid Managed Care shall not be less than 90 days.

14. Managed Care Reform Act of 2009 Timely Filing of Claims (cont.) Reconsideration process for participating providers Insurer or HMO shall pay the claim if the provider can demonstrate both: The late filing was the result of an unusual occurrence, and The provider has a pattern or practice of timely filing. If demonstrated the insurer MAY impose a 25% penalty. In no case will a claim be considered more than 365 days after the date of service.

15. Managed Care Reform Act of 2009 Adverse Reimbursement Change to a Provider Contract Insurers must provide at least 90 days advance written notice to contracted providers of an adverse reimbursement change. Within 30 days of the notice, the provider may terminate their participation agreement by giving written notice. Such termination would be effective upon the implementation date of the change. “Adverse reimbursement change” shall mean a proposed change that could reasonably be expected to have a material adverse impact on the aggregate level of payment to a health care professional

16. Managed Care Reform Act of 2009 Adverse Reimbursement Change to a Provider Contract (cont.) Notification is not required when: The change is otherwise required by law or is the result of changes in payment policies established by a government agency or by the AMA current CPT guidelines, or Such change is expressly provided for under the terms of the contract by inclusion or reference to a specific fee or fee schedule, reimbursement methodology or payment policy.

17. Managed Care Reform Act of 2009 Coordination of Benefits Section 3224-c prohibits the denial of a claim, in whole or in part, on the basis that another insurers is liable unless there is a reasonable basis to believe another carrier is primary. Permits an insurer or HMO to send a COB questionnaire, however if no information is received within 45 days, the claim must be adjudicated. The claim can’t be denied based solely on the insurer not receiving a response to the questionnaire. COB Regulation 178 (Part 217 – Subpart 2) sets forth rules about coordinating benefits in those cases where the insurer has a basis to believe they are not primary.

18. Managed Care Reform Act of 2009 Overpayment Recovery Section 3224-b expands the overpayment recovery requirements to facilities. 30 day advance written notice is required before recoupment of overpayment Insurers cannot go back more than 24 months unless suspicion of fraud or abusive billing. Requires that providers be given an opportunity to challenge the recovery request. Plans must establish written policies & procedures. State government and municipality coverage is carved out of the 24 month look back limit.

19. Managed Care Reform Act of 2009 Provisional Provider Credentialing A physician will be considered provisionally credentialed and may participate in the insurer’s network if: They are newly licensed or recently relocated to New York and did not previously practice in this state, They submit a completed application, They join a group practice of providers, each of whom participate with the insurer, and The application is neither approved or declined within 90 days.

20. Managed Care Reform Act of 2009 Provisional Provider Credentialing (cont.) The provisionally credentialed physician may not be designated as a PCP until fully credentialed. Participation begins on the 91st day after receipt of the completed application and will last until the final credentialing determination. The group practice must request the provisional credentialing in writing. If the application is ultimately denied, the provider or the group must: Refund all payments by the insurer for the in-network services in excess of the out-of-network benefits and Shall not pursue reimbursement from the insured, except to collect the in-network co-pay or coinsurance.

21. Managed Care Reform Act of 2009 Provisional Provider Credentialing Prompt Pay interest and penalties shall not be applicable based on the denial of a claim submitted during the time a provider is provisionally credentialed. Claims submitted by a provisionally credentialed provider cannot ultimately be denied for timely filing This process may require an appeal by the provider.

22. New York Insurance Department Questions?