New York Laws
Title 11 - Medical Assistance for Needy Persons
367-B - Medical Assistance Information and Payment System.

(b) The department of health, in consultation with the office of
Medicaid inspector general, shall develop, test and implement new
methods to strengthen the capability of the medical assistance
information and payment system to detect and control fraud and improve
expenditure accountability, and is hereby authorized to enter into
further agreements with fiscal and/or information technology agents for
the development, testing and implementation of such new methods. Any
such agreements shall be with agents which have demonstrated expertise
in the areas addressed by the agreement. Such methods shall, at a
minimum, address the following areas:
(1) Prepayment claims review. Develop, test and implement an automated
claims review process which, prior to payment, shall subject medical
assistance program services claims to review for proper coding and such
other review as may be deemed necessary. Services subject to review
shall be based on: the expected cost-effectiveness of reviewing such
service; the capabilities of the automated system for conducting such a
review; and the potential to implement such review with negligible
effect on the turnaround of claims for provider payment or on recipient
access to necessary services. Such initiative shall be designed to
provide for the efficient and effective operation of the medical
assistance program claims payment system by performing functions
including, but not limited to, capturing coding errors, misjudgments,
incorrect or multiple billing for the same service and possible excesses
in billing or service use, whether intentional or unintentional.
(2) Coordination of benefits. Develop, test and implement an automated
process to improve the coordination of benefits between the medical
assistance program and other sources of coverage for medical assistance
recipients. Such initiative shall initially examine the savings
potential to the medical assistance program through retrospective review
of claims paid which shall be completed not later than January

thirty-first, two thousand seven. If, based upon such initial
experience, the Medicaid inspector general deems the automated process
to be capable of including or moving to a prospective review, with
negligible effect on the turnaround of claims for provider payment or on
recipient access to services, then the Medicaid inspector general in
subsequent tests shall examine the savings potential through
prospective, pre-claims payment review.
(3) Comprehensive review of paid claims. Take all reasonable and
necessary actions to intensify the state's current level of monitoring,
analyzing, reporting and responding to medical assistance program claims
data maintained by the state's medical assistance information and
payment system contract agents. Pursuant to this initiative, the
department of health, in collaboration with the office of Medicaid
inspector general, shall make efforts to improve the utilization of such
data in order to better identify fraud and abuse within the medical
assistance program and to identify and implement further program and
patient care reforms for the improvement of such program. In addition,
the department of health, in consultation with such contract agents and
the office of Medicaid inspector general, shall identify additional data
elements that are maintained and otherwise accessible by the state,
directly or through any of its contractors, that would, if coordinated
with medical assistance data, further increase the effectiveness of data
analysis for the management of the medical assistance program. To
further the objectives of this subparagraph, the department of health,
in collaboration with the office of Medicaid inspector general, shall
provide or arrange in-service training for state and county medical
assistance personnel to increase the capability for state and local data
analysis, leading to a more cost-effective operation of the medical
assistance program.
(4) Targeted claims and utilization review. Develop, test and
implement an automated process for the targeted review of claims,
services and/or populations not later than January thirty-first, two
thousand seven. Such review shall be for the purposes of identifying
statistical aberrations in the use or billing of such services and for
assisting in the development and implementation of measures to ensure
that service use and billing are appropriate to recipients' needs.
(c) The commissioner of health shall prepare and submit an interim
report to the governor and legislature on the implementation of the
initiatives specified in paragraph (b) of this subdivision no later than
December first, two thousand seven. Such report shall also include
recommendations for any revisions that would further facilitate the
goals of such paragraph, including recommendations for expansion. In
addition, the commissioner of health shall submit a final report not
later than December first, two thousand eight. In preparing such interim
and final reports, the commissioner of health shall consult with the
Medicaid inspector general, third-party agents, providers and recipients
associated with the implementation of paragraph (b) of this subdivision.
9. (a) In order to accomplish a more orderly transition to the medical
assistance information and payment system authorized by this section,
and to continue for a limited transition period the rate at which
advanced revenues have been made available by local governmental units
to certain hospitals providing services to persons eligible for medical
assistance, the department is authorized to promulgate regulations
establishing a system of accelerated payments to hospitals meeting the
criteria set forth in this section.
(b) Such system of accelerated payments shall only be available to a
general hospital, other than a public general hospital:
(i) which prior to January first, nineteen hundred seventy-eight
received regular, periodic and recurring advanced revenues from a local
governmental unit, the amount of which was based on anticipated medical
assistance claims payments; and
(ii) which has demonstrated that its continued financial viability
depends in substantial part on the rate at which such advanced revenues
were made available by local governmental units prior to the time the
department, pursuant to this section, assumed payment for such hospital
responsibilities on behalf of the social services district in which it
is located, taking into account any funds remaining available from the
local governmental unit under its system of advanced revenues. For
purposes of this subdivision, it shall be presumed that a hospital does
not depend in substantial part on the rate at which advanced revenues
were made available by a local governmental unit if it received such
revenues for a period of less than nine months preceding the month in
which the department assumed payment responsibilities for such hospital;
(iii) for which payment responsibility is initially assumed by the
department pursuant to this section during the period beginning June
first, nineteen hundred seventy-eight and ending November thirtieth,
nineteen hundred seventy-eight; and
(iv) which meets performance criteria established by department
regulation relating to the ratio of acceptable claims for patient days
submitted for medical assistance payment compared to the total patient
days of the hospital and compared to such claims submitted in one or
more previous months, and the time lapse between the date the service
was provided and the date the claim was submitted.
(c) The regulations promulgated by the department pursuant to
paragraph (a) of this subdivision shall provide that the amount of the
accelerated payment for any month shall be determined for each hospital
meeting the criteria set forth in this section on the basis of
acceptable medical assistance claims submitted by the hospital in one or
more previous months and the amount of accelerated revenues made
available to the hospital by a local governmental unit prior to the time
the department assumed payment responsibilities for the hospital. The
amount of the accelerated payment for any given month shall not exceed
the amount of a monthly aggregate claim to be submitted by the hospital
to the department, which claim shall reflect items of care, services and
supplies authorized under the medical assistance program pursuant to
this title which are in fact provided prior to the date of the aggregate
claim to persons who have been determined eligible for medical
assistance, or based on the past performance of the hospital are likely
to be determined eligible for medical assistance, when no other source
of payment including third party health insurance and payments pursuant
to title eighteen of the Federal Social Security Act are available for
such items of care, service and supplies. Such aggregate claims shall be
subject to the audit and warrant of the state comptroller.
(d) Any schedule of accelerated payments established by the department
pursuant to this section shall assure that such payments are made for a
period of no more than six months from the month in which the department
assumes payment responsibility for the hospital, and shall provide for
repayment of any amounts in excess of current audited claims, through
reductions in current claims, at a rate that will assure full repayment
at the earliest time consistent with the purposes of this section, but
in no event more than twenty-four months following the month in which
the department assumes payment responsibilities for the hospital.
However, where the commissioner of health has determined with the
concurrence of the state hospital review and planning council that a
hospital has satisfied the department of health regulations and is or

has been authorized to participate in the emergency hospital
reimbursement program pursuant to which repayment of all or part of any
accelerated payments made by the department have been deferred in
accordance with such regulations, notwithstanding the time limitations
set forth above repayment of such deferred amounts shall be made in
accordance with an orderly schedule of repayment established by the
commissioner of health after consultation with the commissioner. In no
event shall any reduction be made against current claims, grant funds or
any amounts due said hospital in settlement of rate appeals, claims or
lawsuits to satisfy such repayment obligations.
(e) In making accelerated payments pursuant to this subdivision and
department regulations, the department shall utilize federal funds made
available, and local funds, for such purposes or for purposes of payment
by the department of medical assistance payments pursuant to this
section.
* 10. a. For the purpose of timely payment, the department is hereby
authorized to develop a concurrent payment system for general hospitals
which elect to participate in the concurrent payment system and which
are included in the payment component of the medical assistance
information and payment system, and to promulgate regulations to govern
such a system. The department may implement the concurrent payment
system for any general hospital which has elected to participate and for
which the department has chosen to implement the system.
b. For all participating general hospitals the department shall
determine a biweekly concurrent payment which shall equal one
twenty-sixth of the portion of the hospital's imputed or certified
inpatient revenue cap (as defined in section twenty-eight hundred
seven-a of the public health law) allocated for medical assistance
payments. The concurrent payment shall be reviewed at the beginning of
each quarter and adjusted to reflect any changes to the inpatient
revenue cap or portion allocated for medical assistance payments.
c. The department shall promulgate regulations, consistent with
federal requirements for participation, governing the concurrent payment
system. The regulations shall address, among other things, the method
of calculating the concurrent payment, the method of reconciliation, the
adjustment of the concurrent payment for the calculated difference, the
manner of eliminating underpayments or overpayments to hospitals in
exceptional circumstances such as significantly changing utilization,
changes in bed or service capacity, or imminent insolvency. The
department shall promulgate regulations establishing a procedure for
recognizing open cases as of the date of reconciliation. The department
shall also promulgate regulations setting forth standards for the
timeliness and quality of billings and may lower the concurrent payment
calculated in accordance with paragraph b of this subdivision for
noncompliance with such regulations.
d. Any payment claims made to the department for days of inpatient
care provided prior to the effective date of this subdivision shall be
paid or denied in accordance with department regulations in effect when
the care was provided.
e. For any general hospital which is not afforded the opportunity of
participating in the concurrent payment system and which is in
compliance with the billing requirements of the department, the
department shall pay any financing or working capital charge levied by
the hospital as authorized in section twenty-eight hundred seven-a of
the public health law.
f. This subdivision shall be effective only if federal participation
is available.
* NB Expires January 1, 1986

11. a. For the purpose of timely payment, the department is hereby
authorized to develop a concurrent payment system for general hospitals
which elect to participate in the concurrent payment system and which
are included in the payment component of the medical assistance
information and payment system, and to promulgate regulations to govern
such a system. The department may implement the concurrent payment
system for any general hospital which has elected to participate and for
which the department has chosen to implement the system.
b. For all participating general hospitals the department shall
determine a biweekly concurrent payment which shall equal one
twenty-sixth of the hospital's estimated yearly inpatient revenue from
medical assistance payments. The concurrent payment shall be reviewed at
the beginning of each quarter and adjusted to reflect any changes to the
rates for medical assistance payments.
c. The department shall promulgate regulations, consistent with
federal requirements for participation, governing the concurrent payment
system. The regulations shall address, among other things, the method
of calculating the concurrent payment, the method of reconciliation, the
adjustment of the concurrent payment for the calculated difference, the
manner of eliminating underpayments or overpayments to hospitals in
exceptional circumstances such as significantly changing utilization,
changes in bed or service capacity, or imminent insolvency. The
department shall promulgate regulations establishing a procedure for
recognizing open cases as of the date of reconciliation. The department
shall promulgate regulations setting forth standards for the timeliness
and quality of billings and may lower the concurrent payment calculated
in accordance with paragraph b of this subdivision for noncompliance
with such regulations.
d. Any payment claims made to the department for days of inpatient
care provided prior to the effective date of this subdivision shall be
paid or denied in accordance with department regulations in effect when
the care was provided.
e. For any general hospital which is not afforded the opportunity of
participating in the concurrent payment system and which is in
compliance with the billing requirements of the department, the
department shall pay any financing or working capital charge levied by
the hospital as authorized in section twenty-eight hundred seven-a of
the public health law.
f. This subdivision shall be effective only if federal participation
is available.
12. (a) For the purpose of regulating cash flow for general hospitals,
the department shall develop and implement a payment methodology to
provide for timely payments for inpatient hospital services eligible for
case based payments per discharge based on diagnosis-related groups
provided during the period January first, nineteen hundred eighty-eight
through March thirty-first two thousand twenty-six, by such hospitals
which elect to participate in the system.
(b) In developing a payment methodology the department shall consider
a system under which hospitals may be reimbursed on the basis of
inpatient admissions, adjusted to payment on the basis of discharge
data, with reconciliations established at time periods specified by the
department. Under such a system variances between amounts paid on an
admission basis and actual amounts due and to be paid on a discharge
basis may be reflected in the amounts to be paid in a subsequent period.
13. Notwithstanding any inconsistent provision of law, in lieu of
payments authorized by this chapter and/or any of the general fund or
special revenue other appropriations made to the office of temporary and
disability assistance and the office of children and family services,

from funds otherwise due to local social services districts or in lieu
of payments of federal funds otherwise due to local social services
districts for programs provided under the federal social security act or
the federal food stamp act or the low income home energy assistance
program, funds in amounts certified by the commissioner of the office of
temporary and disability assistance or the commissioner of the office of
children and family services or the commissioner of health as due from
local social services districts as their share of payments made pursuant
to this section, may be set-aside by the state comptroller in an
interest-bearing account with such interest accruing to the credit of
the locality, pursuant to an estimate provided by the commissioner of
health of a local social services district's share of medical assistance
payments, except that in the case of the city of New York, such
set-aside shall be subject first to the requirements of a section of the
chapter of the laws of two thousand one which enacted this provision,
and then subject to the requirements of paragraph (i) of subdivision (b)
of section two hundred twenty-two-a of chapter four hundred seventy-four
of the laws of nineteen hundred ninety-six prior to the application of
this subdivision. Should funds otherwise payable to a local social
services district from appropriations made to the office of temporary
and disability assistance, the office of children and family services,
and the department of health be insufficient to fully fund the amounts
identified by the commissioner of health as necessary to liquidate the
local share of payments to be made pursuant to this section on behalf of
the local social services district, the commissioner of health may
identify other state or federal payments payable to that local social
services district or any other county agency including, but not limited
to the county department of health, from appropriations made to the
state department of health, and may authorize the state comptroller,
upon no less than five days written notice to such local social services
district or such other county agency, to set-aside such payments in the
interest-bearing account with such interest accruing to the credit of
the locality. Upon such determination by the commissioner of health that
insufficient funds are payable to a local social services district and
any other county agency receiving payments from the office of temporary
and disability assistance, the office of children and family services,
and the state department of health from appropriations made to these
agencies, the state comptroller shall, upon no less than five days
written notice to such local social services district or such other
county agency, withhold payments from any of the general fund - local
assistance accounts or payments made from any of the special revenue -
federal local assistance accounts, provided, however, that such federal
payments shall be withheld only after such federal funds are properly
credited to the county through vouchers, claims or other warrants
properly received, approved, and paid by the state comptroller, and
set-aside such disbursements in the interest-bearing account with such
interest accruing to the credit of the locality until such time that the
amount withheld from each county is determined by the commissioner of
health to be sufficient to fully liquidate the local share of payments,
as estimated by the commissioner of health, to be made pursuant to this
section on behalf of that local social services district.
14. Notwithstanding any other provision of law, effective on or before
January first, two thousand one, the local social services district
share of medical assistance payments made by the state on behalf of the
local social services district shall be paid to the state by the local
social services district using electronic funds transfer under the
supervision of the state comptroller and pursuant to rules and
regulations of the commissioner of health. The state comptroller shall

deposit such funds in the medicaid management information system
statewide escrow fund to the credit of each local district. In the event
that the state comptroller and commissioner of health determine that
there are insufficient funds available from the local district to
liquidate their local share of medical assistance payments, the
commissioner of health shall issue a repayment schedule to the state
comptroller for purposes of reducing reimbursement from other sources of
payment from the state to the city or county of which the local social
services district is a part in accordance with subdivision thirteen of
this section, until the amounts due from the local district are
recovered in full plus any interest that would have otherwise accrued to
the fund had such fund had sufficient balances from the local district.
Upon determination by the state comptroller that insufficient sources of
payment are available to fully liquidate the local social services
district share of medical assistance payments, the commissioner of
health shall include in such schedule a charge to the county equal to
the amount of interest otherwise earned by the state short-term interest
pool, plus any interest penalty as the commissioner of health may
determine, until such time as the district has fully liquidated its
liability pursuant to the provisions of this chapter.

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