New York Allows Audits of Non-Participating Providers

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.