Bill S5155-2013

Relates to the provisional credentialing of physicians

Relates to the provisional credentialing of physicians.

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  • Jan 8, 2014: REFERRED TO INSURANCE
  • May 13, 2013: REFERRED TO INSURANCE

Memo

BILL NUMBER:S5155

TITLE OF BILL: An act to amend the insurance law and the public health law, in relation to provider credentialing

PURPOSE: The purpose of this bill is to permit newly licensed providers, providers moving to New York State, or a physician who has changed their corporate relationship such that it results in the issuance of a new tax identification number under which their services are billed for, who are employed by licensed Article 28 facilities and have applied to be credentialed as part of a health plan's provider network to be considered provisionally credentialed from the date the health plan receives the hospital and physicians completed sections of the plan's credentialing application and the plan is notified in writing that the physician has been granted hospital privileges .

SUMMARY OF PROVISIONS:

Section 1 of the bill amends subsection (a) of Section 4803 of the insurance law by adding a new paragraph (3) that provides that newly licensed physicians, physicians that have recently relocated to the state or a physician who has changed their corporate relationship such that it results in the issuance of a new tax identification number under which their services are billed for, who are employed by a licensed Article 28 facility whose other employed health care professionals participate in the in-network portion of a health plan's network shall be considered provisionally credentialed from the date the health insurer receives the hospital and physician's completed sections of the insurer's credentialing application and the insurer is notified in writing that the physician has been granted hospital privileges.

Section 2 amends Subsection 1 of Section 446-d of the public health law by adding a new paragraph (c) that provides that newly licensed physicians, physicians that have recently relocated to the state or a physician who has changed their corporate relationship such that it results in the issuance of a new tax identification number under which their services are billed for, who are employed by a licensed Article 28 facility whose other employed health care professionals participate in the in-network portion of a health plan's network shall be considered provisionally credentialed from the date the health plan receives the hospital and physician's completed sections of the plan's credentialing application and the plan is notified in writing that the physician has been granted hospital privileges.

Section 3 is the effective date.

EXISTING LAW: The latest of the managed care reform laws (Chapter 237 of the Laws of 2009) provided that newly licensed health care professionals or health care professionals that recently relocated to New York State who joined a group practice of health care professionals and have applied to be credentialed as part of the in-network of a health plan's network are considered provisionally credentialed if their application is not approved or denied with 90 days from the date of application.

JUSTIFICATION: The model of care delivery is gradually shifting from a physician private practice model to a model of hospital or health system employed physicians. In fact, a leading physician recruiting firms (Merritt Hawkins) has predicted that by 2015, over 75% of newly hired physicians will be hospital employees. In order to recruit and retain physicians, upstate hospitals in a market of increasing physician shortage have been forced to be at the forefront of this shifting model of care. However, faced with increasingly constrained revenue from Medicare and Medicaid cuts and commercial health plans, hospitals, who most often lose money on physicians services component of care even with full payment, cannot carry afford to carry a physician on salary for 90 days without reimbursement for their services nor based on the physician shortage can they afford to be without the services of these physicians.

Hospitals as licensed and regulated Article 28 facilities are statutorily required to credential any provider before extending admitting privileges or allowing the professional to provide care within the facility. According to both hospitals and health plan administrators it is almost unheard of for a hospital itself to employ any physician who would be unsuitable for health plan credentialing.

All too often credentialing decisions and notification are delayed by simple administrative processes such has the delayed paperwork or the next scheduled meeting of the health plan's credentialing committee, The legislation would allow the hospitals to maximize the use of scarce health manpower and to be reimbursed for the services their employed physicians provide. The bill also provide for strict financial controls whereby the payments for all services provided to the health plans' enrollees are held and only after the health plan fully credentials the provider, are the payments for services rendered transmitted. Should a health plan, in rare cases, and for valid reasons elect not to credential a hospital employed physician then the payments to the hospital by the health plan are limited to the out of network payment, should the enrollee have coverage for out-of-network care.

LEGISLATIVE HISTORY: New Bill

FISCAL IMPLICATIONS: None

LOCAL FISCAL IMPLICATIONS: None

EFFECTIVE DATE: This bill is effective ninety days after which it shall have become law, and applies to applications submitted after that date, and shall not apply submitted prior to such date if such application is resubmitted in substantially similar form on or after the date on which this act shall have become law.


Text

STATE OF NEW YORK ________________________________________________________________________ 5155 2013-2014 Regular Sessions IN SENATE May 13, 2013 ___________
Introduced by Sen. VALESKY -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance AN ACT to amend the insurance law and the public health law, in relation to provider credentialing THE PEOPLE OF THE STATE OF NEW YORK, REPRESENTED IN SENATE AND ASSEM- BLY, DO ENACT AS FOLLOWS: Section 1. Subsection (a) of section 4803 of the insurance law is amended by adding a new paragraph 3 to read as follows: (3) A NEWLY-LICENSED PHYSICIAN, A PHYSICIAN WHO HAS RECENTLY RELOCATED TO THIS STATE FROM ANOTHER STATE AND HAS NOT PREVIOUSLY PRACTICED IN THIS STATE, OR A PHYSICIAN WHO HAS CHANGED HIS OR HER CORPORATE RELATIONSHIP SUCH THAT IT RESULTS IN THE ISSUANCE OF A NEW TAX IDENTIFI- CATION NUMBER UNDER WHICH SUCH PHYSICIAN'S SERVICES ARE BILLED FOR, WHO IS EMPLOYED BY A GENERAL HOSPITAL LICENSED PURSUANT TO ARTICLE TWENTY-EIGHT OF THE PUBLIC HEALTH LAW, AND WHOSE OTHER EMPLOYED PHYSI- CIANS PARTICIPATE IN THE IN-NETWORK PORTION OF AN INSURER'S NETWORK, SHALL BE DEEMED "PROVISIONALLY CREDENTIALED" AND MAY PARTICIPATE IN THE IN-NETWORK PORTION OF AN INSURER'S NETWORK UPON : (I) THE INSURER'S RECEIPT OF THE HOSPITAL AND PHYSICIAN'S COMPLETED SECTIONS OF THE INSUR- ER'S CREDENTIALING APPLICATION; AND (II) THE INSURER BEING NOTIFIED IN WRITING THAT THE HEALTH CARE PROFESSIONAL HAS BEEN GRANTED HOSPITAL PRIVILEGES PURSUANT TO THEIR REQUIREMENTS OF SECTION TWENTY-EIGHT HUNDRED FIVE-K OF THE PUBLIC HEALTH LAW. HOWEVER, A PROVISIONALLY CREDENTIALED PHYSICIAN SHALL NOT BE DESIGNATED AS AN INSURED'S PRIMARY CARE PHYSICIAN UNTIL SUCH TIME AS THE PHYSICIAN HAS BEEN FULLY CREDEN- TIALED BY THE INSURER. AN INSURER SHALL NOT BE REQUIRED TO MAKE ANY PAYMENTS TO THE LICENSED GENERAL HOSPITAL FOR SERVICES PROVIDED BY A PROVISIONALLY CREDENTIALED PHYSICIAN, UNTIL AND UNLESS THE PHYSICIAN IS FULLY CREDENTIALED BY THE INSURER, PROVIDED, HOWEVER, THAT UPON BEING FULLY CREDENTIALED, THE LICENSED GENERAL HOSPITAL SHALL BE PAID FOR ALL SERVICES THAT THE CREDENTIALED PHYSICIAN PROVIDED TO THE INSURER'S
INSUREDS FROM THE DATE THE PHYSICIAN FULLY MET THE REQUIREMENTS TO BE PROVISIONALLY CREDENTIALED PURSUANT TO THIS PARAGRAPH. SHOULD THE APPLI- CATION ULTIMATELY BE DENIED BY THE INSURER, THE INSURER SHALL NOT BE LIABLE FOR ANY PAYMENT TO THE LICENSED GENERAL HOSPITAL FOR THE SERVICES PROVIDED BY THE PROVISIONALLY CREDENTIALED HEALTH CARE PROFESSIONAL THAT EXCEED ANY OUT-OF-NETWORK BENEFITS PAYABLE UNDER THE INSURED'S CONTRACT WITH THE INSURER; AND THE LICENSED GENERAL HOSPITAL SHALL NOT PURSUE REIMBURSEMENT FORM THE INSURED, EXCEPT TO COLLECT THE COPAYMENT OR COIN- SURANCE THAT OTHERWISE WOULD HAVE BEEN PAYABLE HAD THE INSURED RECEIVED SERVICES FROM A HEALTH CARE PROFESSIONAL PARTICIPATING IN THE IN-NETWORK PORTION OF AN INSURER'S NETWORK. S 2. Subdivision 1 of section 4406-d of the public health law is amended by adding a new paragraph (c) to read as follows: (C) A NEWLY-LICENSED PHYSICIAN, A PHYSICIAN WHO HAS RECENTLY RELOCATED TO THIS STATE FROM ANOTHER STATE AND HAS NOT PREVIOUSLY PRACTICED IN THIS STATE, OR A PHYSICIAN WHO HAS CHANGED HIS OR HER CORPORATE RELATIONSHIP SUCH THAT IT RESULTS IN THE ISSUANCE OF A NEW TAX IDENTIFI- CATION NUMBER UNDER WHICH SUCH PHYSICIAN'S SERVICES ARE BILLED FOR, WHO IS EMPLOYED BY A GENERAL HOSPITAL LICENSED PURSUANT TO ARTICLE TWENTY-EIGHT OF THIS CHAPTER, AND WHOSE OTHER EMPLOYED PHYSICIANS PARTICIPATE IN THE IN-NETWORK PORTION OF A HEALTH CARE PLAN'S NETWORK, SHALL BE DEEMED "PROVISIONALLY CREDENTIALLED" AND MAY PARTICIPATE IN THE IN-NETWORK PORTION OF A HEALTH CARE PLAN'S NETWORK UPON: (I) THE PLAN'S RECEIPT OF THE HOSPITAL AND PHYSICIAN'S COMPLETED SECTION OF THE PLAN'S CREDENTIALING APPLICATION; AND (II) THE HEALTH CARE PLAN BEING NOTIFIED IN WRITING THAT THE HEALTH CARE PROFESSIONAL HAS BEEN GRANTED HOSPITAL PRIVILEGE PURSUANT TO THE REQUIREMENTS OF SECTION TWENTY-EIGHT HUNDRED FIVE-K OF THIS CHAPTER. HOWEVER, A PROVISIONALLY CREDENTIALED PHYSICIAN SHALL NOT BE DESIGNATED AS AN ENROLLEE'S PRIMARY CARE PHYSICIAN UNTIL SUCH TIME AS THE PHYSICIAN HAS BEEN FULLY CREDENTIALED BY THE HEALTH CARE PLAN. A HEALTH CARE PLAN SHALL NOT BE REQUIRED TO MAKE ANY PAYMENTS TO THE LICENSED GENERAL HOSPITAL FOR SERVICED PROVIDED BY A PROVI- SIONALLY CREDENTIALED PHYSICIAN, UNTIL AND UNLESS THE PHYSICIAN IS FULLY CREDENTIALED BY THE HEALTH CARE PLAN, PROVIDED HOWEVER THAT UPON BEING FULLY CREDENTIALED, THE LICENSED GENERAL HOSPITAL SHALL BE PAID FOR ALL SERVICES THAT THE CREDENTIALED PHYSICIAN PROVIDED TO THE HEALTH PLAN'S ENROLLEES FROM THE DATE THE PHYSICIAN FULLY MET THE REQUIREMENTS TO BE PROVISIONALLY CREDENTIALED PURSUANT TO THIS PARAGRAPH. SHOULD THE APPLI- CATION ULTIMATELY BE DENIED BY THE HEALTH CARE PLAN, THE HEALTH CARE PLAN SHALL NOT BE LIABLE FOR ANY PAYMENT TO THE LICENSED GENERAL HOSPI- TAL FOR THE SERVICES PROVIDED BY THE PROVISIONALLY CREDENTIALED HEALTH CARE PROFESSIONAL THAT EXCEED ANY OUT-OF-NETWORK BENEFITS PAYABLE UNDER THE ENROLLEE'S CONTRACT WITH THE HEALTH CARE PLAN AND THE LICENSED GENERAL HOSPITAL SHALL NOT PURSUE REIMBURSEMENT FORM THE ENROLLEE, EXCEPT TO COLLECT THE COPAYMENT OR COINSURANCE THAT OTHERWISE WOULD HAVE BEEN PAYABLE HAD THE ENROLLEE RECEIVED SERVICES FROM A HEALTH CARE PROFESSIONAL PARTICIPATING IN THE IN-NETWORK PORTION OF AN INSURER'S NETWORK. S 3. This act shall take effect on the ninetieth day after it shall have become a law, and shall apply to applications submitted on or after such date and shall not apply to applications submitted prior to such date if such application is resubmitted in substantially similar form on or after the effective date of this act.

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