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 • Administer 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 • Changes 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. Health Insurance in New York 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. Health Insurance in New York • Timely Filing of Claims • 120 days after date of service for claims submitted by providers and subscribers. • Contract may provide more time but cannot be less than 120 days. • Medicaid Managed Care shall not be less than 90 days.

14. Health Insurance in New York • 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. Health Insurance in New York • 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. Health Insurance in New York • 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. Health Insurance in New York • 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. Health Insurance in New York • 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. New York Insurance Department Questions?