Summary#
A-11688 would amend New York’s Insurance Law; it is not law and has been referred to the Assembly Insurance Committee. It would bar covered insurers and other entities from reducing a participating provider’s negotiated payment for covered evaluation-and-management or procedural services solely because the provider also billed other health care services on the same day. Its stated goal is to reduce inequities in access to medical procedures.
- A barred payment-reduction term in a participating provider agreement would be void and unenforceable.
- The ban would cover same-day billing of other health care services, including minor procedures.
- For plans where an insurer or utilization review organization only provides administrative services, its duty would be limited to recommending that the third-party payer authorize coverage and payment under the bill.
- The bill would apply to contracts and policies issued, renewed, modified, or amended on or after it takes effect.
What it means for you#
- Participating providers: For covered services, an insurer or other entity subject to the law could not reduce the negotiated rate solely because you also billed other health care services that day. The bill does not guarantee payment for services that are not otherwise covered.
- Insurers and other covered entities: You would have to follow the ban, and any provider-agreement term allowing a prohibited reduction would be unenforceable.
- Patients and plan members: The bill does not directly change which services are covered or create a new benefit. For plans with an administrative-services-only insurer or review organization, the bill requires a recommendation to the third-party payer, not a direction to that payer to approve payment.
Money#
The available material gives no cost estimate or spending amount.
- The bill does not specify public spending, fees, fines, or staffing.
- Any effect on payments to providers or costs to payers is not estimated.
What is unclear#
- The supplied materials do not include the current version of the Insurance Law being amended, so the bill’s interaction with existing rules and statutory definitions could not be checked.
- The bill does not define key terms in its text, including “negotiated rate” and “other health care services.”
- It does not set out a complaint, review, appeal, or enforcement process.
- For plans where an insurer or review organization only provides administrative services, the bill does not say what happens if the third-party payer does not follow its recommendation.
- The bill says it would take effect immediately, but applies only to contracts and policies issued, renewed, modified, or amended on or after that date. It does not explain how that rule would apply to a particular contract change.
Case for#
- The bill appears intended to prevent providers from receiving a reduced negotiated payment for covered services solely because they billed other services on the same day.
- Making prohibited contract terms void could give providers a clear basis to challenge those terms.
- The bill’s limit for administrative-services-only arrangements recognizes that the insurer or review organization may not be the entity that decides or pays claims.
Case against#
- One concern is that the bill restricts payment reductions even when a provider bills multiple services on the same day; the text does not explain how that restriction would affect payment arrangements.
- It is unclear how the ban would apply when a reduction has more than one reason, since it bars reductions made “solely” because other services were billed.
- For administrative-services-only plans, the bill requires only a recommendation. The third-party payer’s response is not specified.