Health Care Provider Rights and Responsibilities
(Insurance Law Sections 3217-b, 3224-a, 3224-b, 3241, 4325, 4803 and Public Health Law Sections 23, 24, 4403, 4406-c & 4406-d)
The Insurance Law and Public Health Law include important protections for health care providers with respect to network participation, provider contracting, claims processing, prompt payment for health care services, and dispute resolution for surprise bills and bills for emergency services. Some protections apply to all HMO and insurance coverage, while others apply only to HMO coverage and to managed care coverage offered by insurers (which most insurers do not offer).* The Public Health Law also includes disclosure requirements for health care providers.
Participation in a Health Plan's Network:
- Any Willing Provider. New York does not have an any willing provider law and HMOs and insurers are not required to accept any provider who wishes to join their network.
- Network Adequacy. HMOs and insurers are required to maintain a provider network that is sufficient to meet the health needs of insureds and provide an appropriate choice of provider.
- Network Application and Qualification. HMOs and insurers offering a managed care plan are required to make available, upon request, written application procedures and minimum qualification requirements that a health care professional is required to meet to be considered for participation in the health plan's network.
- Credentialing of Providers. HMOs and insurers offering a managed care plan are required to complete review of a health care professional's application to participate in their network within 90 days.
- Notification. HMOs and insurers offering a managed care plan are required to notify the health care professional as to whether the health care professional is credentialed or not, or if additional time is needed in spite of the health plan's best efforts or because the health plan is waiting for additional information from a third party. The health plan is also required to make every effort to obtain the information as soon as possible.
- Timeframe. If an incomplete health care professional application is received, or if the HMO or insurer offering a managed care plan is not currently accepting additional health care professionals of the applicant's type, the health plan should respond to the health care professional with such notice as soon as possible, but no later than 90 days from receipt of the application.
- Provisionally Credentialed. A health care professional who is newly-licensed or has relocated to New York and has not previously practiced in New York can be "provisionally credentialed" if the health care professional joins a group practice of health care professionals that participates with a health plan, submits a completed credentialing application, and does not receive a response to the application within 90 days. The provisionally credentialed health care professional is considered a participating provider as of the day following the 90th day of the health plan's receipt of the completed application and until the health plan issues a determination on the credentialing application. The group practice is required to notify the health plan in writing that if the credentialing application is denied, the group practice or the health care professional will: (1) refund any payments made for in-network services that exceed the insured's out-of-network benefits; and (2) not pursue the insured for any payments that exceed the insured's in-network cost-sharing.
- The provisionally credentialed health care professional may not be designated as a primary care physician until he or she is fully credentialed.
- Interest and penalties under the Prompt Pay Law do not apply to claim denials submitted during the provisionally credentialed period, but nothing prevents a health plan from paying a claim for a provisionally credentialed health care professional.
- A health plan may not deny a claim upon appeal for services provided by a provisionally credentialed health care professional solely based on the ground that the claim was not timely filed.
Required Provider Contract Provisions. HMOs and all insurers are required to include the following items in participating provider contracts:
- Payment Calculation. The method by which payments to the provider will be calculated, including any retrospective or prospective adjustments;
- Time Periods. The time periods within which calculations will be completed, the dates payments and adjustments will be due, and the dates upon which payments and adjustments will be made;
- Information Relied Upon. A description of the information relied upon to calculate payments or adjustments, and how a provider can access a summary of the calculations or adjustments;
- Dispute Process. The process to resolve disputed, incorrect or incomplete information, and the process to adjust payments which were made using the incorrect or incomplete information; and
- Arbitration. The right of either party to seek arbitration under Article 75 of the Civil Practice Laws and Rules for disputes regarding payment terms of the contract.
- Liability. HMOs and insurers cannot transfer liability to the provider (other than a medical group for HMOs) for activities, actions or omissions of the health plan.
- Financial Risk. HMOs and insurers cannot transfer financial risk to providers in a manner inconsistent with Public Health Law Section 4403(1)(c) or penalize providers for unfavorable case mix so as to jeopardize the quality of or the insured's appropriate access to medically necessary services.
- Adverse Reimbursement Change. HMOs and insurers are required to give health care professionals at least 90 days written notice before implementing a contract change that could have a material adverse impact on the provider's aggregate level of payment, unless such change is otherwise required by law or required because of changes in fee schedules, reimbursement methodology or payment policies established by a government agency or the American Medical Association's current procedural terminology (CPT) codes, reporting guidelines and conventions, or is expressly provided under the terms of the contract. If the health care professional objects to the change, the health care professional may give written notice to terminate the contract within 30 days of the date of notice of the change, and termination will be effective on the implementation date of the change.
- Hospital Emergency Admissions. HMOs and insurers are not permitted to deny payment to a hospital for a claim for medically necessary inpatient services resulting from an emergency admission solely because the hospital did not timely notify such insurer that the services had been provided. HMOs, insurers and hospitals may agree to requirements for timely notification of medically necessary inpatient services resulting from an emergency admission and to reduction in payment for failure to timely notify, provided that:
- Any requirement for timely notification provides for a reasonable extension of timeframes for emergency services provided on weekends or federal holidays;
- Any agreed to reduction in payment for failure to timely notify does not exceed $2,000 or 12% of the payment amount due for the services, whichever is less; and
- Any agreed to reduction in payment for failure to timely notify shall not be imposed if the hospital could not determine, after reasonable efforts, the patient's insurance coverage at the time the inpatient services were provided.
Termination of Provider Contracts:
- Explanation of Reasons. HMOs and insurers offering a managed care plan cannot terminate a participating health care professional's contract unless the health plan gives the health care professional a written explanation of the reasons for the proposed contract termination and an opportunity for a review or hearing. This requirement does not apply in cases of imminent harm to patient care, a determination of fraud, or a final disciplinary action by a state licensing board that impairs the provider's ability to practice.
- Notice Requirements. HMOs and insurers offering a managed care plan are required to include the following in a notice of a proposed contract termination:
- The reasons for the proposed action;
- Notice that the health care professional has the right to request a hearing or review, at the health care professional's discretion, before a panel appointed by the health plan;
- A time limit of not less than 30 days within which the health care professional may request the hearing; and
- A time limit for a hearing date which is required to be held within not less than 30 days after the date the hearing was requested.
- Hearings. HMOs and insurers offering a managed care plan are required to adhere to the following requirements with respect to any hearing:
- The hearing panel is required to be made up of three persons appointed by the health plan. At least one member of the panel is required to be a clinical peer reviewer in the same discipline and the same or similar specialty as the health care professional under review. The panel may consist of more than three persons however one third are required to be clinical peers.
- The hearing panel is required to render a timely decision. Decisions shall include reinstatement of the health care professional, provisional reinstatement of the provider subject to conditions, or termination. Decisions are required to be in writing.
- A hearing panel's decision to terminate the health care professional will be effective at least 30 days after the health care professional receives the decision. However, the termination cannot be effective earlier than 60 days from the receipt of the notice of termination.
- Hospital Cooling Off Period. If a contract between an HMO or insurer and a hospital is not renewed or is terminated by either party, the parties are required to continue to abide by the terms of the contract for two months from the date of termination or, in the case of a non-renewal, from the end of the contract period. Within 15 days after the commencement of the two month period, notice is required to be provided to all potentially affected insureds. This requirement does not apply when both parties mutually agree in writing to the termination or non-renewal and the HMO or insurer provides notice to the insured at least 30 days before the termination. The Department of Health can also waive the two-month period upon the request of either party to a contract that is being terminated for cause.
- Non-renewal of a Participating Provider Contract. Either the health plan or the health care professional may exercise the right of non-renewal at the expiration of an HMO contract or a managed care contract offered by an insurer. If no express expiration date is given, either the health care professional or the health plan can exercise the right of non-renewal each January 1st upon 60 days notice to the other party. A non-renewal is not considered a termination and no appeal rights are granted.
Performance and Practice Information:
- Evaluation Information. HMOs and insurers offering a managed care contract are required to develop policies and procedures to ensure that participating health care professionals are regularly informed of the information maintained by the health plan to evaluate the performance or practice of health care professionals.
- Provider Profiling. HMOs and insurers offering a managed care contract are required to consult with health care professionals when developing methodologies to collect and analyze provider profiling data.
- Profiling Data. Any profiling data used by an HMO or insurer offering a managed care contract to evaluate health care professionals is required to be measured against stated criteria and an appropriate group of participating health care professionals using similar treatment modalities serving comparable patient populations.
- Opportunity to Discuss. Health care professionals have to be given the opportunity to discuss the unique nature of the health care professional's patient population which may have a bearing on the provider's profile and to work cooperatively with the HMO or insurer offering a managed care contract to improve the health care professional's performance.
- Impermissible Termination. No HMO or insurer offering a managed care contract may terminate or refuse to renew a participating health care professional's contract solely because the health care professional has:
- Advocated on behalf of a patient.
- Filed a complaint against the health plan.
- Appealed a decision of the health plan.
- Provided information or filed a report with an appropriate government body regarding the health plan's actions.
- Reasons for Termination. No participating health care professional contract with an HMO or insurer offering a managed care contract may contain provisions which supersede or impair the health care professional's right to a notice of reasons for the termination and an opportunity for a hearing.
Patient Care and Treatment:
Treatment Information. HMOs and insurers cannot restrict a provider from telling their patient:
- All treatments available for the patient's condition, including treatments that may not be covered by the health plan.
- The provisions or terms of the patient's health plan as they relate to the patient.
- Filing Complaints. HMOs and insurers cannot restrict a provider from filing a complaint to an appropriate governmental body regarding policies or procedures the provider believes may negatively impact the quality of care or access to care.
- Patient Advocacy. HMOs and insurers cannot prohibit or restrict a provider from advocating on behalf of a patient for coverage of a particular treatment.
- Accept Claims. HMOs and insurers are required to accept and initiate the processing of all health care claims submitted by physicians that are consistent with the current version of the American Medical Association's CPT codes, reporting guidelines and conventions and the centers for Medicare and Medicaid services (CMS) health care common procedure coding system (HCPCS).
- Claim Denials Reasons. HMOs and insurers may determine that a claim is not eligible for payment, in full or in part, based on a determination that:
- The claim is not complete;
- The service provided is not a covered benefit under the contract or policy;
- The insured did not obtain a referral or pre-certification or satisfy any other condition precedent to receive covered benefits from the physician;
- The covered benefit exceeds the benefit limits of the contract or agreement;
- The person is not eligible for coverage or is otherwise not compliant with the terms and conditions of his or her contract;
- Another HMO or insurer is liable for all or part of the claim; or
- The plan has a reasonable suspicion of fraud or abuse.
- Claims Software. HMOs and insurers are required to provide the name of the commercially available claims editing software product that the health plan utilizes and any significant edits on their provider websites and in provider newsletters. Health plans are also required to provide such information upon the written request of a participating physician.
- Claim Submission. HMOs and insurers are required to accept claims submitted in writing, including through the internet, by e-mail or by fax.
Prompt Payment of Health Care Claims:
- Time to File Claims. Providers are required to submit health care claims within 120 days after the date of service for the claims to be valid and enforceable against HMOs and insurers, unless the parties agree to a time period that is more favorable to the provider. (Providers are required to submit claims within 90 days after the date of service for Medicaid managed care plans.)
- Promptly Pay Claims. HMOs and insurers are required to pay claims for health care services within 30 days of receipt if the claims are submitted through the internet or by e-mail and within 45 days of receipt if the claims are submitted on paper or by fax, except in cases where the obligation to make payment is not reasonably clear or there is evidence that the bill may be fraudulent.
- Obligation To Pay. If the obligation to pay is not reasonably clear, an HMO or insurer shall pay any undisputed portion of the claim and either notify the member or provider, in writing, within 30 calendar days of the receipt of the claim that the health plan is not obligated to pay and the reasons, or request additional information needed to determine liability to pay the claim or make the payment.
- Timeframe. Upon receipt of the information requested, or an appeal of a claim for the denied health care services, an HMO or insurer shall comply with the 30 or 45 day requirement for clean claims.
- Reconsideration. Participating health care providers may request reconsideration of a claim that is denied solely because it was untimely submitted. If the provider can demonstrate that his or her non-compliance was a result of an unusual occurrence and that he or she has a pattern or practice of timely submitting claims, the HMO or insurer is required to pay such claim, but may reduce the reimbursement due by up to 25% of what the HMO or insurer would have paid had the claim been timely submitted.
- Hospital Claims. Within 30 days of receipt of payment of a claim for which payment has been adjusted based on a particular coding to a patient, a hospital has the opportunity to submit the affected claim with medical records supporting the hospital's initial coding of the claim. Upon receipt, the HMO or insurer is required to review such information to ascertain the correct coding for payment and process the claim in accordance with the timeframes set forth above. If the HMO or insurer processes the claim consistent with its initial determination, it is required to provide a statement with the decision explaining why the initial adjustment was appropriate. If the HMO or insurer increases the payment based on the information submitted by the hospital, but fails to do so within the required timeframes, it is required to pay interest on the amount of such increase at the rate set by the commissioner of taxation and finance for corporate taxes, computed from the end of the 45 day period after resubmission of the additional medical record information.
- Violation. Each claim or bill processed after the 30 or 45 day time period is a separate violation.
- Payment of Interest. For any violation of the prompt payment law, interest is due. Interest is calculated as the greater of: 12% per annum or the rate set by the commissioner of taxation and finance for corporate taxes pursuant to New York Tax Law Section 1096(e)(1). Interest is calculated from the date the claim or health care payment was required to be made. When the amount of interest due is less than two dollars, the HMO or insurer is not required to pay the interest.
- To report a prompt payment violation to the Department, please click here.
Overpayment Recovery Efforts:
Notice. Other than recovery for duplicate payments, HMOs and insurers are required to give providers 30 days' notice before engaging in overpayment recovery efforts. The notice is required to include:
- The patient's name;
- Service date;
- Payment amount;
- Proposed adjustment; and
- A reasonably specific explanation of the proposed adjustment.
- Opportunity to Challenge. HMOs and insurers are required to give providers the opportunity to challenge an overpayment recovery and are required to establish written policies and procedures for providers to follow when challenging the recovery. Any such challenge is required to set forth the specific grounds for the challenge.
- Time Limit for Starting Overpayment Recoveries. HMOs and insurers are only permitted to initiate overpayment recovery within 24 months of the date the original payment was received by the provider, except in cases involving fraud, intentional misconduct, abusive billing or when initiated at the request of a self-funded plan, required by a federal or state government program or coverage that is provided by the State or a municipality to its employees, retirees or members.
- Offsets. If a provider asserts underpayment of a claim, the HMO or insurer may defend or offset the assertion by overpayments that were made within the timeframe extending as far back as to the underpayment in question. If the underpayment is confirmed, the HMO or insurer may lessen or balance the amount owed to the provider by identifying an amount the HMO or insurer overpaid to the provider from the time of the underpayment to the present. However, the HMO or insurer may not collect overpayments in excess of the provider underpayment, unless the overpayment occurred within the last 24 months or an exception applies as described above.
Physician Responsibility For Claim Forms:
- Patient Bills. A non-participating physician is required to include a claim form for a third-party payor with a patient bill for health care services, other than for a bill for the patient's copayment, coinsurance or deductible.
- Assignment of Benefits Form. If the non-participating physician is billing the patient for a surprise bill (services provided in a participating hospital or ambulatory surgical facility or a referral to a non-participating provider without the patient's consent), the non-participating physician is also required to include an assignment of benefits form with the patient's bill and the claim form. For more information regarding what is a surprise bill, see What You Need To Know About Surprise Bills If You Are A Health Care Provider.
Health Care Professional and Physician Disclosure Requirements:
When Scheduling Appointments. A health care professional, or a group practice of health care professionals, a diagnostic and treatment center or a health center defined under 42 USC §254b on behalf of health care professionals rendering services at the group practice, diagnostic and treatment center or health center, is required to disclose to patients or prospective patients the following information:
- Health Plan Participation. The health plans in which the health care professional, group practice, diagnostic and treatment center or health center is a participating provider. This is required to be given in writing or through a website prior to the provision of non-emergency services and verbally at the time an appointment is scheduled.
- Hospital Affiliations. The hospitals with which the health care professional is affiliated. This is required to be given in writing or through a website prior to the provision of non-emergency services and verbally at the time an appointment is scheduled.
- Cost of Services. That the amount or estimated amount that the health care professional will bill the patient for health care services is available upon request if the health care professional does not participate with a patient's or prospective patient's health plan. Health care professionals are required to provide this information to patients prior to the provision of non-emergency services. Upon receipt of a request from a patient or prospective patient, the health care professional is required to disclose to the patient or prospective patient in writing the amount or estimated amount that will be billed for health care services provided or anticipated to be provided absent unforeseen medical circumstances. With respect to a health center, this may be provided in the form of a schedule of fees provided under 42 USC §254b(k)(3)(G)(i).
- Physicians Arranging Services in His or Her Office or Coordinating or Referring a Patient for Services. A physician that schedules a health care provider to perform anesthesiology, laboratory, pathology, radiology or assistant surgeon services in connection with care to be provided in his or her office, or a physician that coordinates or refers a patient for such services, is required to provide a patient or prospective patient with the following at the time of referral to or coordination with such provider:
- The provider's name, if the physician schedules a specific provider in a practice.
- The provider's practice.
- The provider's address.
- The provider's telephone number.
- Physicians Arranging for Inpatient or Outpatient Services in a Hospital. A physician that arranges for any other physicians to treat a patient during the patient's scheduled hospital admission or scheduled outpatient hospital services is required to provide the patient and the hospital, at the time non-emergency services are scheduled, with the following information regarding the other physicians whose services are scheduled at the time of the pre-admission testing, registration or admission:
- The physician's name, if the physician schedules a specific physician in the practice.
- The physician's practice.
- The physician's address.
- The physician's telephone number.
- How to determine the health plans in which the physician participates.
Hospital Disclosure Requirements:
Hospital Website. A hospital is required to post on its website:
- Charges. A list of its standard charges for items and services provided by the hospital (or how to obtain this information if the list of charges is not posted).
- Health Plan Participation. The health plans in which it is a participating provider.
- A Statement Providing the Following Information About Charges of Physicians in the Hospital:
- That physician services provided in the hospital are not included in the hospital's charges.
- That physicians who provide services in the hospital may or may not participate with the same health plans as the hospital.
- That the prospective patient should check with the physician arranging for the hospital services to determine the health plans in which the physician participates.
- Physician Groups With Which the Hospital Has Contracted. The name, address, and telephone number of the physician groups that the hospital has contracted with to provide services such as anesthesiology, pathology or radiology, and instructions how to contact these groups to determine the health plan participation of the physicians in the groups.
- Physicians Employed By The Hospital. The name, address, and telephone number of physicians employed by the hospital and whose services may be provided at the hospital, and the health plans in which they participate.
- Registration or Admission Materials. A hospital is required, in registration or admission materials provided prior to non-emergency hospital services, to:
- Advise a Patient or Prospective Patient to Contact the Physician Arranging the Hospital Services to Determine:
- The name, practice name, address, and telephone number of any other physician whose services will be arranged by the physician.
- Whether the services of physicians who are employed or contracted by the hospital to provide services such as anesthesiology, pathology and radiology are reasonably anticipated to be provided to the patient.
- Provide Patients With Instructions on How to Determine Physicians' Health Plan Participation. Provide patients or prospective patients with information as to how to timely determine the health plans participated in by physicians who are reasonably anticipated to provide services to the patient at the hospital and who are employees of the hospital or contracted by the hospital to provide services including anesthesiology, pathology and radiology.
- Advise a Patient or Prospective Patient to Contact the Physician Arranging the Hospital Services to Determine:
Independent Dispute Resolution (IDR) For Emergency Services And Surprise Bills
- Independent Dispute Resolution (IDR). You have a right to IDR to dispute a health plan payment for emergency physician services or for a surprise bill. See The Independent Dispute Resolution Process.
- Surprise Bills. It will be a surprise bill if your patient receives services from a non-participating physician at a participating hospital or ambulatory surgical center and: (1) A participating physician was not available; or (2) a non-participating physician provided services without your patient's knowledge; or (3) unforeseen medical circumstances arose at the time the health care services were provided. It will also be a surprise bill if your patient is referred by a participating physician to a non-participating provider and your patient did not sign a written consent acknowledging that the services would be out-of-network and would result in costs not covered by the patient's health plan. A referral occurs: (1) During the course of a visit with a participating doctor, a non-participating provider treats the patient; or (2) the patient's participating doctor takes a specimen from the patient in the office (for example, blood) and sends it to a non-participating laboratory or pathologist; or (3) for any other health care services when referrals are required under the patient's plan.
- Assignment of Benefits Form. When your patient signs an assignment of benefits form for a surprise bill, your patient will only be responsible for paying you the in-network cost-sharing. You are required to hold your patient harmless for any amounts in excess of your patient's in-network cost-sharing. The health plan is required to pay you the billed amount or to attempt to negotiate reimbursement with you. If attempts to negotiate do not result in a resolution of the payment dispute, the health plan will pay you an amount that it determines is reasonable. You may dispute the amount that the health plan pays you through the independent dispute resolution process.
Obtaining Additional Information.
- For a copy of the IDR Law click here.
- For a copy of the IDR Regulation click here.
- For a copy of the Out-of-Network (OON) Law Guidance click here.
* Please note, managed care coverage offered by an insurer is defined as a contract which requires that all health care services be provided by a referral from a primary care provider and that services be rendered by a provider participating in the insurer's network. In addition, in the case of an individual contract or a group contract covering no more than 300 lives, imposing a co-insurance obligation of more than 25% upon out-of-network services, which has been sold to five or more groups, managed care coverage also includes a contract which requires all services be provided pursuant to a referral from a primary care provider and that services provided pursuant to the referral be rendered by a participating provider in order for the member to obtain the maximum reimbursement.