165.861           Violations of State Insurance Laws by Managed Care Organizations and Private Insurers: 

MSSNY will take the following action:

  1. Seek legislation or other appropriate means to a) prohibit health insurance companies from demanding refunds from physicians without providing physicians a detailed audit report which clearly identifies the claims in question and the methodology utilized to arrive at the alleged overpayment amount; b) eliminate or establish a more objective definition of the “abusive billing” exception to the two year current statutory limitation on health plan overpayment recoveries c) permit physicians a meaningful opportunity to appeal a requested refund demand including review by an independent body and d) prohibit automatic offset provisions in physician contracts;
  2. Work to assure that the New York State Insurance Department and Attorney General’s office appropriately investigate and resolve complaints made by physicians regarding violations of the New York State Insurance Law by health plans, including violations of: the Prompt Payment law; laws that limit refund demands and recoveries; and laws which specify a minimum period of time to submit claims;
  3. Educate and encourage physicians to submit suspected violations of these laws to the New York State Insurance Department and Attorney General. (HOD 2011-55; Reaffirmed HOD 2013-258 and 2013-57; Reaffirmed HOD 2021-56)