Health Care Provider Rights
(Insurance Law Sections 3217-b, 3224-a, 3224-b, 4325, 4803 and Public Health Law Sections 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, and prompt payment for health care services. Some protections apply to all HMO and insurance coverage, while others apply only to HMO coverage and to managed care contracts offered by insurers (which most insurers do not offer).*
Participation in a Health Plans Network:
- 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.
- HMOs must maintain a network that is sufficient to deliver comprehensive services to their enrolled population.
- HMOs and insurers offering a managed care contract must make available, upon request, written application procedures and minimum qualification requirements that a provider must meet to be considered for participation in the health plans network.
HMOs and insurers offering a managed care contract must complete review
of a providers application to participate in their network within
- HMOs and insurers offering a managed care contract must notify the provider as to whether the provider is credentialed or not, or if additional time is needed in spite of the health plans best efforts or because the health plan is waiting for additional information from a third party. The health plan must also make every effort to obtain the information as soon as possible.
- If an incomplete provider application is received or if the HMO or insurer offering a managed care contract is not currently accepting additional providers of the applicants type, the health plan should respond to the provider with such notice as soon as possible, but no later than 90 days from receipt of the application.
HMOs and all insurers must include the following items in participating
- The method by which payments to the provider will be calculated, including any retrospective or prospective adjustments;
- The time periods within which calculations will be completed, the dates payments and adjustments will be due, and the rates upon which payments and adjustments will be made;
- 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;
- 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
- 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.
- HMOs and insurers cannot transfer liability to the provider for activities, actions or omissions of the health plan.
Termination of Provider Contracts:
- HMOs and insurers offering a managed care contract cannot terminate a participating provider contract unless the health plan gives the provider 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 providers ability to practice.
- HMOs and insurers offering a managed
care contract must include the following in a notice of a proposed contract termination:
- The reasons for the proposed action;
- Notice that the provider has the right to request a hearing or review, at the providers discretion, before a panel appointed by the health plan;
- A time limit of not less than thirty days within which the provider may request the hearing; and
- A time limit for a hearing date which must be held within not less than thirty days after the date the hearing was requested.
- HMOs and insurers offering a managed care contract must adhere to the
following requirements with respect to any hearing:
- The hearing panel must be made up of three persons appointed by the health plan. At least one member of the panel must be a clinical peer reviewer in the same discipline and the same or similar specialty as the provider under review. The panel may consist of more than three persons however one third must be clinical peers.
- The hearing panel must render a timely decision. Decisions shall include reinstatement of the provider, provisional reinstatement of the provider subject to conditions, or termination. Decisions must be in writing.
- A hearing panels decision to terminate the provider will be effective at least thirty days after the provider receives the decision. However, the termination cannot be effective earlier than sixty days from the receipt of the notice of termination.
Non-renewal of a Participating Provider Contract:
- Either the health plan or the provider 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 provider or the health plan can exercise the right of non-renewal each January 1st upon sixty days notice to the other party. A non-renewal is not considered a termination and no appeal rights are granted.
Performance and Practice Information:
- HMOs and insurers offering a managed care contract must develop policies and procedures to ensure that participating providers are regularly informed of the information maintained by the health plan to evaluate the performance or practice of providers.
- HMOs and insurers offering a managed care contract must consult with health care professionals when developing methodologies to collect and analyze provider profiling data.
- Any profiling data used by an HMO or insurer offering a managed care contract to evaluate providers must be measured against stated criteria and an appropriate group of participating providers using similar treatment modalities serving comparable patient populations.
- Providers must be given the opportunity to discuss the unique nature of the health care professionals patient population which may have a bearing on the providers profile and to work cooperatively with the HMO or insurer offering a managed care contract to improve the providers performance.
- No HMO or insurer offering a managed care contract may terminate or
refuse to renew a participating provider contract solely because the
- 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 plans actions.
- No participating provider contract with an HMO or insurer offering a managed care contract may contain provisions which supersede or impair the providers right to a notice of reasons for the termination and an opportunity for a hearing.
Patient Care and Treatment:
HMOs and insurers cannot restrict a provider from telling their patient:
- All treatments available for the patients condition, including treatments that may not be covered by the health plan.
- The provisions or terms of the patients health plan as they relate to the patient.
- 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.
- HMOs and insurers cannot prohibit or restrict a provider from advocating on behalf of a patient for coverage of a particular treatment.
- HMOs and insurers must accept and initiate the processing of all health care claims submitted by physicians that are consistent with the current version of the American Medical Associations current procedural terminology (CPT) codes, reporting guidelines and conventions and the centers for Medicare and Medicaid services (CMS) health care common procedure coding system (HCPCS).
- HMOs and insurers must 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 must also provide such information upon the written request of a participating physician.
Overpayment Recovery Efforts:
Other than recovery for duplicate payments, HMOs and insurers must give
physicians thirty days notice before engaging in overpayment recovery
efforts. The notice must include:
- The patients name;
- Service date;
- Payment amount;
- Proposed adjustment; and
- A reasonably specific explanation of the proposed adjustment.
- HMOs and insurers must initiate overpayment recovery within twenty-four months of the date the original payment was received by the physician, except in cases involving fraud, intentional misconduct, abusive billing or when initiated at the request of a self funded plan or required by a federal or state government program.
- If a physician 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 physician by identifying an amount the HMO or insurer overpaid to the physician from the time of the underpayment to the present. However, the HMO or insurer may not collect overpayments in excess of the physician underpayment, unless the overpayment occurred within the last 24 months or an exception applies as described above.
Prompt Payment of Health Care Claims:
- Health care providers must be paid timely for their claims. HMOs and insurers are required to pay claims for health care services within 45 days of receipt, except in cases where the obligation to make payment is not reasonably clear or there is evidence that the bill may be fraudulent.
- If the obligation to pay is not reasonably clear, then 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.
- 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 45 day requirement for clean claims.
- Each claim or bill processed after the 45 day time period is a separate violation.
- If an HMO or insurer violates the prompt payment law, the HMO or insurer must pay interest on the claim. 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 should have been made. However, 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 of Financial Services, please select this link.
* Please note, a managed care contract 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 insurers 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, a managed care contract 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.