The NYS Governor signed legislation which is a major first step in addressing several problems that physicians have had in dealing with reimbursement delays and credentialing. Provisions of this new law:
- Prohibit HMOs and other insurers from demanding refunds from a physician more than two years after the claim was initially paid. This provision does not include situations involving fraud or abusive billing. Some health plans have been known to demand refunds for claims that were paid up to six years back.
- Require 30 days notice to providers when the insurer is seeking a refund. Some HMOs have been known to merely offset the amount demanded against future payment owed to a physician with little or no notice.
- Require insurers to accept and initiate the processing of claims that are consistent with the AMA’s CPT codes, guidelines and conventions
- Require some “transparency” in how insurers determine reimbursement amount. Health plans will be required to provide the name of the commercially-available coding software they use.
- Require health plans to complete a provider’s application to join a panel within 90 days, except in cases where a third party has not provided the necessary documentation