health insurance in new york laura dillon, principal examiner new york insurance department consumer...

Health Insurance in New York

Laura Dillon, Principal ExaminerNew York Insurance Department

Consumer Services BureauOne Commerce Plaza

Albany NY 12257(518) 486-9105

[email protected]

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


Consumer Services Bureau Investigate complaints against all

Department licensees Insurers, HMOs, Agents, Brokers, Adjusters,

Service Contract Providers

Administer the External Appeal process


• 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.


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


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


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)


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


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.


• 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.


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


Contractual Issues (cont.)• Beware of requesting special handling

for certain types of services.• Technology limits can cause problems

with the processing of these claims.


• 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.


• 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.


• 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


• 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.


• 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.


• 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.


Questions?

health insurance in new york laura dillon, principal examiner new york insurance department consumer...

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