New York Healthcare Law Blog

Does the 2009 Managed Care Reform Act offer the much-needed relief to the New York healthcare providers dealing with health insurance plans? Enacted in July 2009, this legislation comes at a time when the entire nation is living in anticipation of a possible overhaul of the health care system.

The Reform Act was a product of lengthy negotiations among New York's key players in the managed care arena and is the latest and broadest of a series of managed care reform efforts that include the External Appeal Law,the Prior Authorization Law, the Cooling-Off Law, and the Prompt-Pay Law.

The Managed Care Reform Act of 2009 addresses several important objectives of health care providers. Specifically, the Act shortens the 45-day claim payment time framed under the Prompt-Pay Law. In addition, a health plan is now required to provide notice of disputed claims within 30 days of receipt, stating specific reasons of the denial of claim. Further, a health plan is prohibited from denying a claim on the basis of "Coordination of Benefits" with another potentially liable payor and may not delay adjudication of a claim because it is waiting for a patient questionnaire to be returned. Even if some request for information from patient is not returned promptly, the health plan must adjudicate the claim within the mandated time frame. Additionally, the Reform Act explicitly provides that physicians and other heatlh care provider have 120 days from the date of service to submit a claim to for payment.

The Reform Act does offer hope of curbing injurious managed care practices. Of course, as is usually the case with novel reform efforts, the new legislation is not a fix-all in the current managed care system. Clearly, additional regulatory efforts are necessary to protect health care providers in their skewed dealings with the health plans.