A law went into effect on March 31, 2015 that protects consumers from surprise bills when services are performed by a non-participating (out-of-network) doctor at a participating hospital or ambulatory surgical center in your HMO or insurer's network or when a participating doctor refers an insured to a non-participating provider. The new law also protects all consumers from bills for emergency services.
The following information explains what you need to know about these important new protections if:
Hold Harmless Protections for Insured Patients. Your health plan must protect you from bills for out-of-network emergency services in a hospital if you have coverage through an HMO or insurer subject to NY law (coverage that is not self-insured). You do not have to pay non-participating provider charges for emergency services (typically for services in a hospital emergency room) that are more than your in-network co-payment, coinsurance or deductible (this protection may only apply when your health insurance coverage renews after March 31, 2015). Let your health plan know if you receive a bill from a non-participating provider for emergency services.
Uninsured Patients or Patients With Employer or Union Self-insured Coverage. You may be able to file a dispute through the independent dispute resolution process if you do not have HMO or insurance coverage that is subject to New York Law (for example, if you are uninsured or your employer or union self-insures) and you receive a bill from a doctor for emergency services provided on and after March 31, 2015 in New York that you believe is excessive.
Doctors. You may dispute the amount that the health plan pays you for emergency services through the independent dispute resolution process if you do not participate with a patient's health plan. However, the following emergency services are exempt from the IDR process: CPT codes 99281 - 99285, 99288, 99291 - 99292, 99217 - 99220, 99224 - 99226, and 99234 - 99236 if the bill does not exceed 120% of the usual and customary cost and the fee disputed is $693.66 (adjusted annually for inflation rates) or less after any applicable co-insurance, co-payment and deductible.
Submit a Dispute Through the Independent Dispute Resolution (IDR) Process
Health Care Providers for Disputes with a Health Plan Involving an Insured Patient. To submit a dispute, health care providers must:
To start the IDR process, Log onto the IDR portal application to obtain a tracking number:
Complete the IDR Provider and Insurer Application
. Send the application to the assigned independent dispute resolution entity.
Uninsured Patients or Patients With Employer or Union Self-Insured Coverage, or Insureds Who Do Not Assign Benefits for Surprise Bills. To submit a dispute, you must complete an IDR Patient Application and send it to NYS Department of Financial Services, Consumer Assistance Unit/IDR Process, One Commerce Plaza, Albany, NY 12257.
Review of Bills by Independent Dispute Resolution Entity (IDRE)
IDR Entity Reviews. Disputes are reviewed by independent dispute resolution entities (IDRE). Decisions will be made by a reviewer with training and experience in health care billing, reimbursement, and usual and customary charges in consultation with a licensed doctor in active practice in the same or similar specialty as the doctor providing the service that is the subject of the dispute.
30 Day Timeframe. The IDRE will make a determination within 30 days of receipt of the dispute.
IDRE Determines The Fee. For disputes involving HMO or insurance coverage, the IDRE chooses either the non-participating provider bill or the health plan payment. For disputes submitted by uninsured patients, or patients with employer or union self-insured coverage, the IDRE determines the fee.
IDRE Considers These Factors When Making a Determination:
- Whether there is a gross disparity between the fee charged by the provider and (1) fees paid to the provider for the same services provided to other patients in health care plans in which the provider is non-participating, and (2) the fees paid by the health plan to reimburse similarly qualified out-of-network providers for the same services in the same region;
- The provider's training, education, experience, and usual charge for comparable services when the provider does not participate with the patient's health plan;
- The circumstances and complexity of the case;
- Patient characteristics; and
- The usual and customary cost of the service.
IDRE may direct a good faith negotiation for settlement if settlement is likely or if the health plan's payment and the provider's fee are unreasonably far apart.
Review is Binding. The review is admissible in court.
Payment for Independent Dispute Resolution (IDR)
Disputes Between a Provider and a Health Plan, Involving an Insured Patient.
Disputes involving a Patient who is not an Insured.
- Provider pays the cost of the dispute resolution when the IDRE determines that the health plan's payment is reasonable.
- Health plan pays the cost of the dispute resolution when the IDRE determines that the provider's fee is reasonable.
- Provider and the health plan share the prorated cost when there is a settlement.
- There may be a minimal fee to the provider or health plan submitting the dispute if the dispute is found ineligible or incomplete.
- The doctor pays the cost of the dispute resolution when the IDRE determines that the doctor's fee is not reasonable.
- The patient pays the cost of the dispute resolution when the IDRE determines that doctor's fee is reasonable, unless it would pose a hardship to the patient. "Hardship" means a household income below 250% of the Federal Poverty Level.
Questions About IDR
If you have questions about IDR call us at (800) 342-3736 or email us at [email protected]