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New York Allows Audits of Non-Participating Providers

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Health insurers doing business in New York state can conduct retrospective reviews of payments made to out-of-network doctors and hospitals, officials say.

The officials, in the Office of General Counsel of the New York State Insurance Department, present that view in an opinion issued in response to a question about insurer audits of out-of-network providers.

New York insurance laws impose a duty on health insurers to conduct fraud audits, Fraud audits - picture of a detectiveand the fraud audit requirements do not distinguish between in-network and out-of-network providers, officials say.

The laws limit the period during which an insurer or health maintenance organization (HMO) can seek recoveries of overpayments to 2 years after the payments were made, but there is no time limit if the insurer or HMO has a reasonable belief that fraud, abusive billing practices or other intentional misconduct could be involved, officials say.

“However, if an insurer or an HMO were to conduct such retrospective audits as a general practice (1) to avoid either paying claims or providing services covered under the contract or (2) in retaliation for a health care provider leaving a network, the department would investigate and take the necessary action against the insurer or HMO,” officials warn.