310.996 Third-Party Payer Use of Unsubstantiated Demand and Refund Letters:
MSSNY will seek amendment to the New York State Insurance Law to address the issue of payer demand letters, and to reflect the following provisions: 1) the physician should have the right to due process, should have access to all pertinent carrier documents, and should have the right to review the post-payment audit sample with appropriate carrier personnel; 2) in post-payment reviews, carriers should not retroactively apply new policy to old claims; 3) where the amount in dispute exceeds $1,000, physicians should have the right to have an independent entity not employed by the third-party payer (such as a Peer Review Organization or the American Arbitration Association) review the results of the carrier’s post-payment review; and 4) third-party payers should not seek repayment through the claims offset process until the physician has exhausted all appeals, and until an accurate overpayment amount has been established. (HOD 2000-279; Reaffirmed HOD 2010-259; Reaffirmed HOD 2020)
