165.893           Changes in the Overpayment Recovery Law:

MSSNY will seek legislation, regulation or other appropriate means to:

  1. assure that meaningful fines and penalties are imposed on health plans that violate the current two-year statutory limitation on health plan refund demands as well as the requirement that health plans provide 30 days notice before initiating efforts to recover an alleged overpayment;
  2. limit the time that health plans can seek repayment of overpayments to physicians to the same time that a physician has to submit a claim;
  3. require that, in the event a physician has paid a recovery to a Managed Care Organization due to erroneously billing the MCO rather than the correct insurer (e.g. no-fault or Workers’ Compensation), the appropriate responsible party be required to honor a claim for the services rendered for a period of 60 days from the date of the recovery. (HOD 08-58; Reaffirmed HOD 2011-55; Reaffirmed HOD 2021)

MSSNY recommends that section 3224-B of the insurance law be amended to require health plans to initiate overpayment proceedings within 2 months (60 days) from the date the claim was paid and will continue to seek the enactment of legislation; regulatory or other means to prohibit using extrapolation to determine refund demand amounts in the absence of fraud or intentional misconduct.  (HOD 2013-55 and 56; Reaffirmed HOD 2021)

MSSNY will work to remove all references to fraud and/or abuse from the State’s refund demand “look back” law and also amend Assembly Bill A.1538 (on the state’s refund demand “look back” law) to (a) require that the law define “reasonable belief” and (b) require insurers to support their “fraud and abuse” allegations with detailed analyses of alleged deficiencies in the charts. MSSNY will also continue to seek legislation that would eliminate the “abusive billing” exception to the statutory look back limit. (HOD 2013-57; Reaffirmed HOD 2021)