Bill Text: NY S03515 | 2019-2020 | General Assembly | Introduced
Bill Title: Enacts provisions relating to comprehensive motor vehicle reparations; provides for limited assignment of benefits; preclusion lift; burden of proof shift; mandatory arbitration; provider decertification; and treatment guidelines.
Spectrum: Bipartisan Bill
Status: (Introduced - Dead) 2020-01-08 - REFERRED TO INSURANCE [S03515 Detail]
Download: New_York-2019-S03515-Introduced.html
STATE OF NEW YORK ________________________________________________________________________ 3515 2019-2020 Regular Sessions IN SENATE February 8, 2019 ___________ Introduced by Sens. BRESLIN, SEWARD -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance AN ACT to amend the insurance law, in relation to comprehensive motor vehicle reparations The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Section 5102 of the insurance law is amended by adding a 2 new subsection (n) to read as follows: 3 (n) "Health service provider" means any medical provider that submits 4 a bill for payment under benefits defined and provided by this section 5 for any of the following: 6 (1) Medical, hospital (including services rendered in compliance with 7 article forty-one of the public health law, whether or not such services 8 are rendered directly by a hospital), surgical, nursing, dental, ambu- 9 lance, x-ray, prescription drug and prosthetic services; 10 (2) Psychiatric, physical therapy (provided that treatment is rendered 11 pursuant to a referral) and occupational therapy and rehabilitation; 12 (3) Any nonmedical remedial care and treatment rendered in accordance 13 with a religious method of healing recognized by the laws of this state; 14 and 15 (4) Any other professional health services. 16 § 2. Subsection (a) of section 5106 of the insurance law is amended by 17 adding two new undesignated paragraphs to read as follows: 18 Payment of the interest penalty and reasonable attorney fees to a 19 claimant when payment of a claim is overdue shall be the exclusive reme- 20 dy when an insurer fails to make timely payment. The failure of an 21 insurer to make timely payment or issue a denial within thirty days 22 after proof of claim has been submitted to an insurer shall not preclude 23 such insurer from issuing a denial or asserting a defense after the 24 thirty day period has elapsed. EXPLANATION--Matter in italics (underscored) is new; matter in brackets [] is old law to be omitted. LBD09656-01-9S. 3515 2 1 The claimant has the burden of proof to show the expenses under para- 2 graph one of subsection (a) of section five thousand one hundred two of 3 this article were medically necessary and in accordance with the appli- 4 cable fee schedule. Evidence of mailing a claim form shall not be suffi- 5 cient to meet this burden. 6 § 3. Subsection (b) of section 5106 of the insurance law, as amended 7 by chapter 452 of the laws of 2005, is amended to read as follows: 8 (b) [Every insurer shall provide a claimant with the option of submit-9ting any dispute] All disputes involving the insurer's liability to pay 10 first party benefits, or additional first party benefits, the amount 11 thereof or any other matter which may arise pursuant to subsection (a) 12 of this section shall be submitted to arbitration pursuant to simplified 13 procedures to be promulgated or approved by the superintendent. Such 14 simplified procedures shall include an expedited eligibility hearing 15 option, when required, to designate the insurer for first party benefits 16 pursuant to subsection (d) of this section. The expedited eligibility 17 hearing option shall be a forum for eligibility disputes only, and shall 18 not include the submission of any particular bill, payment or claim for 19 any specific benefit for adjudication, nor shall it consider any other 20 defense to payment. 21 § 4. The insurance law is amended by adding a new section 5110 to read 22 as follows: 23 § 5110. Assignment of benefits to health service providers. (a) A 24 "covered person" has the right to assign claims for medical expenses 25 under this article to a "health service provider", and such assignment 26 shall afford the health service provider as the assignee, the rights, 27 privileges, and remedies for payment to which a covered person is enti- 28 tled to under this article. However, such assignment is valid only where 29 coverage and compliance with policy terms by the covered person are not 30 in dispute. 31 (b) The covered person shall have the sole right to contest any issues 32 involving coverage or compliance with policy terms by the covered 33 person. 34 (c) The health service provider shall have a lien against any recovery 35 by the covered person for services provided. 36 (d) The health service provider shall not pursue payment for the cost 37 of services arising out of the injuries the covered person sustained due 38 to a motor vehicle accident unless there is a determination that cover- 39 age does not exist. 40 § 5. Section 5109 of the insurance law, as added by chapter 423 of the 41 laws of 2005, is amended to read as follows: 42 § 5109. Unauthorized providers of health services. (a) [The super-43intendent, in consultation with the commissioner of health and the44commissioner of education, shall by regulation, promulgate standards and45procedures for investigating and suspending or removing the authori-46zation for providers of health services to demand or request payment for47health services as specified in paragraph one of subsection (a) of48section five thousand one hundred two of this article upon findings49reached after investigation pursuant to this section. Such regulations50shall ensure the same or greater due process provisions, including51notice and opportunity to be heard, as those afforded physicians inves-52tigated under article two of the workers' compensation law and shall53include provision for notice to all providers of health services of the54provisions of this section and regulations promulgated thereunder at55least ninety days in advance of the effective date of such regulations] 56 As used in this section, "health services" means services, supplies,S. 3515 3 1 therapies or other treatments specified in subparagraph (i), (ii) or 2 (iv) of paragraph one of subsection (a) of section five thousand one 3 hundred two of this article. 4 (b) The [commissioner of health and the commissioner of education5shall provide a list of the names of all providers of health services6who the commissioner of health and the commissioner of education shall7deem, after reasonable investigation, not authorized to demand or8request any payment for medical services in connection with any claim9under this article because such] superintendent may prohibit a provider 10 of health services from demanding or requesting payment for health 11 services rendered under this article, for a period not exceeding three 12 years, if the superintendent determines, after notice and a hearing, 13 that the provider of health services: 14 (1) has admitted to, or been found guilty of, professional [or other] 15 misconduct [or incompetency], as defined in the education law, in 16 connection with [medical] health services rendered under this article; 17 or 18 (2) [has exceeded the limits of his or her professional competence in19rendering medical care under this article or has knowingly made a false20statement or representation as to a material fact in any medical report21made in connection with any claim under this article; or22(3)] solicited, or [has] employed another person to solicit for 23 [himself or herself] the provider of health services or [for] another 24 person or entity, professional treatment, examination or care of [an25injured] a person in connection with any claim under this article; or 26 [(4)] (3) has refused to appear before, or [to] answer any question 27 upon request of, the [commissioner of health, the] superintendent[,] or 28 any duly authorized officer of [the] this state, [any legal question,] 29 or refused to produce any relevant information concerning [his or her] 30 the conduct of the provider of health services in connection with 31 [rendering medical] health services rendered under this article; or 32 [(5)] (4) has engaged in [patterns] a pattern of billing for [services33which were not provided]: 34 (i) health services alleged to have been rendered under this article, 35 when the health services were not rendered; or 36 (ii) unnecessary health services; or 37 (5) utilized unlicensed persons to render health services under this 38 article, when only a person licensed in this state may render the health 39 services; or 40 (6) utilized licensed persons to render health services, when render- 41 ing the health services is beyond the authorized scope of the person's 42 license; or 43 (7) ceded ownership, operation or control of a business entity author- 44 ized to provide professional health services in this state, including 45 but not limited to a professional service corporation, limited liability 46 company or registered limited liability partnership, to a person not 47 licensed to render the health services for which the entity is legally 48 authorized to provide, except where the unlicensed person's ownership, 49 operation or control is otherwise permitted by law; or 50 (8) committed a fraudulent insurance act as defined in section 176.05 51 of the penal law; or 52 (9) has been convicted of a crime involving fraudulent or dishonest 53 practices; or 54 (10) violated any provision of this article or regulations promulgated 55 thereunder.S. 3515 4 1 (c) [Providers] A provider of health services shall [refrain from2subsequently treating for remuneration, as a private patient, any person3seeking medical treatment] not demand or request payment for health 4 services under this article [if such provider pursuant to this section5has been prohibited from demanding or requesting any payment for medical6services under this article. An injured claimant so treated or examined7may raise this as] that are rendered during the term of the prohibition 8 ordered by the superintendent pursuant to subsection (b) of this 9 section. The prohibition ordered by the superintendent may be a defense 10 in any action by [such] the provider of health services for payment for 11 [treatment rendered at any time after such provider has been prohibited12from demanding or requesting payment for medical services in connection13with any claim under this article] such health services. 14 (d) The [commissioner of health and the commissioner of education] 15 superintendent shall maintain [and regularly update] a database contain- 16 ing a list of providers of health services prohibited by this section 17 from demanding or requesting any payment for health services [connected18to a claim] rendered under this article and shall make [such] the infor- 19 mation available to the public [by means of a website and by a toll free20number]. 21 (e) The superintendent may levy a civil penalty not exceeding fifty 22 thousand dollars on any provider of health services that the superinten- 23 dent prohibits from demanding or requesting a payment for health 24 services pursuant to subsection (b) of this section. Any civil penalty 25 imposed for a fraudulent insurance act, as defined in section 176.05 of 26 the penal law, shall be levied pursuant to article four of this chapter. 27 (f) Nothing in this section shall be construed as limiting in any 28 respect the powers and duties of the commissioner of health, commission- 29 er of education [or], the superintendent, or insurer to investigate 30 instances of misconduct by a [health care] provider [and, after a hear-31ing and upon written notice to the provider, to temporarily prohibit a32provider of health services under such investigation from demanding or33requesting any payment for medical services under this article for up to34ninety days from the date of such notice] of health services and take 35 appropriate action pursuant to any other provision of law. A determi- 36 nation of the superintendent pursuant to subsection (b) of this section 37 shall not be binding upon the commissioner of health or the commissioner 38 of education in a professional disciplinary proceeding relating to the 39 same conduct. 40 § 6. Section 5108 of the insurance law is amended to read as follows: 41 § 5108. Limit on charges by providers of health services. (a) The 42 charges for services specified in paragraph one of subsection (a) of 43 section five thousand one hundred two of this article and any further 44 health service charges which are incurred as a result of the injury and 45 which are in excess of basic economic loss, shall not exceed the charges 46 permissible under the schedules prepared and established by the chairman 47 of the workers' compensation board for industrial accidents, except 48 where the insurer or arbitrator determines that unusual procedures or 49 unique circumstances justify the excess charge, and shall be subject to 50 the treatment guidelines established pursuant to subsection (d) of this 51 section. At no time shall an insurer pay any charge that exceeds the 52 charges permissible under the schedule prepared and established by the 53 chair of the workers' compensation board. 54 (b) The superintendent, after consulting with the chairman of the 55 workers' compensation board and the commissioner of health, shall 56 promulgate rules and regulations implementing and coordinating theS. 3515 5 1 provisions of this article and the workers' compensation law with 2 respect to charges for the professional health services specified in 3 paragraph one of subsection (a) of section five thousand one hundred two 4 of this article, including the establishment of schedules for all such 5 services for which schedules have not been prepared and established by 6 the chairman of the workers' compensation board, including, but not 7 limited, to durable medical equipment or supplies. Additionally, the 8 superintendent, after consultation with the workers' compensation board 9 and the commissioner of health, shall promulgate treatment guidelines 10 with the respect of treating covered persons. Charges for services that 11 are not specifically scheduled by the superintendent of insurance or the 12 chairman of the workers' compensation board, or are not compensable 13 charges under Medicare are not compensable health service charges under 14 subsection (a) of section five thousand one hundred two of this article. 15 (c) No provider of health services specified in paragraph one of 16 subsection (a) of section five thousand one hundred two of this article 17 may demand or request any payment in addition to the charges authorized 18 pursuant to this section. No such provider may be reimbursed for any 19 services unless the provider complies with subsection (d) of this 20 section. Every insurer shall report to the commissioner of health any 21 patterns of overcharging, excessive treatment or other improper actions 22 by a health provider within thirty days after such insurer has knowledge 23 of such pattern. 24 (d) Notwithstanding any other provision of the statute, rule or regu- 25 lation to the contrary, the following shall apply for all individuals or 26 entities that provide, treat, or charge for services specified in para- 27 graph one of subsection (a) of section five thousand one hundred two of 28 this article: 29 (1) The treating provider shall follow the treatment guidelines estab- 30 lished by the superintendent; 31 (2) Deviations from the treatment guidelines may be permitted under 32 the following conditions: 33 (i) prior written or electronic request is given to the insurer prior 34 to commencing treatment. The request shall contain justification for the 35 deviation from the treatment guidelines. The burden of showing the 36 necessity of the deviation remains solely on the treating provider. 37 Failure to provide this request shall result in a maximum reimbursement 38 of fifty percent of the treatment guidelines. 39 (ii) the insurer shall not be precluded from evaluating the deviation 40 for payment during the pendency of the review, and may utilize peer 41 review for evaluation of the deviation. 42 (iii) any disputes shall be resolved through a panel of experts who 43 have been trained or certified in the treatment guidelines pursuant to 44 subsection (e) of section five thousand one hundred six of this article. 45 (3) An insurer may schedule an independent medical examination at any 46 time during the course of treatment. 47 (4) Services or supplies not covered by the treatment guidelines or 48 the workers' compensation fee schedule shall not be compensable. 49 § 7. Section 5106 of the insurance law is amended by adding a new 50 subsection (e) to read as follows: 51 (e) Every insurer shall provide the treating provider with the option 52 of submitting a dispute involving a request for deviations from the 53 treatment guidelines under subsection (d) of section five thousand one 54 hundred eight of this article to arbitration pursuant to simplified 55 procedures promulgated or approved by the superintendent. Such simpli-S. 3515 6 1 fied procedures shall include arbitration through a panel of experts who 2 have been trained or certified in the treatment guidelines. 3 § 8. Subsection (b) of section 3425 of the insurance law is amended by 4 adding a new undesignated paragraph to read as follows: 5 Notwithstanding any rule, law or regulation to the contrary, an insur- 6 er may rescind, or retroactively cancel to the inception of the policy, 7 coverage for personal injury protection under article fifty-one of this 8 chapter where there is nonpayment of the initial premium or initial 9 installment within the first sixty days, or where it is discovered that 10 the payment proceeds or identity of the purported policyholder were 11 stolen. A person who is injured during this period may have recourse 12 under a personal policy of insurance or to the motor vehicle indemnifi- 13 cation corporation provided such person did not participate in any frau- 14 dulent activity, including but not limited to, a staged or intentionally 15 caused accident. 16 § 9. This act shall take effect immediately and shall apply to all 17 actions and proceedings commenced on or after such date; and shall also 18 apply to any action or proceeding which was commenced prior to such 19 effective date where, as of such date, a trial of the issues has not yet 20 commenced.
