Surprise Medical Bills and Emergency Services
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:
- you have coverage with an HMO or insurer subject to New York law;
- you are uninsured or your employer or union provides self-insured coverage that is not subject to New York law; or
- you are a health care provider.
Dispute a Surprise Medical Bill
When you receive services from a non-participating doctor at a participating hospital or ambulatory surgical center, the bill you receive for those services will be a surprise bill if:
- A participating doctor was not available; or
- A non-participating doctor provided services without your knowledge; or
- Unforeseen medical circumstances arose at the time the health care services were provided.
- It will not be a surprise bill if you chose to receive services from a non-participating doctor instead of from an available participating doctor.
When you are referred by your participating doctor to a non-participating provider, the bill you receive for those services will be a surprise bill if you did not sign a written consent that you knew the services would be out-of-network and would result in costs not covered by your health plan.
A referral to a non-participating provider occurs when:
- During the course of a visit with your participating doctor, a non-participating provider treats you; or
- Your participating doctor takes a specimen from you in the office (for example, blood) and sends it to a non-participating laboratory or pathologist; or
- For any other health care services when referrals are required under your plan.
Protect Yourself From A Surprise Bill. If you have a fully funded NY Health plan you will be protected from a surprise bill and you will only be responsible for your in-network copayment, coinsurance or deductible if you:
- Sign AOB Form.Sign an Assignment Of Benefits form to permit your provider to seek payment for the bill from your health plan; AND
- Send Form and Bill. Send the form to your health plan and provider and include a copy of the bill or bills you do not think you should pay.
Uninsured Patients or Patients With Employer or Union Self-Insured Coverage, or Insureds Who Do Not Assign Benefits for Surprise Bills
If you are uninsured or your employer or union self-insures, you may dispute a surprise bill for services provided by a doctor at a hospital or ambulatory surgical center when they have not given you all the required information about your care.
To submit a dispute, you must complete the IDR Patient Application and send it to;
NYS Department of Financial Services
Consumer Assistance Unit/IDR Process
One Commerce Plaza, Albany, NY 12257
Health Care Providers for Disputes with a Health Plan Involving an Insured Patient
If your patient has coverage through an HMO or insurer subject to NY law (coverage that is not self-insured):
- Hospital and Ambulatory Surgical Center. A bill will be a surprise bill if your patient receives services from a non-participating doctor at a participating hospital or ambulatory surgical center and: (1) a participating doctor was not available; or (2) a non-participating doctor provided services without your patient's knowledge; or (3) unforeseen medical circumstances arose at the time the health care services were provided.
- Referral. A bill will also be a surprise bill if your patient is referred by a participating doctor to a non-participating provider and your patient did not sign a written consent acknowledging that the services would be out-of-network and would result in costs not covered by the patient's health plan. A referral occurs: (1) during the course of a visit with a participating doctor, a non-participating provider treats the patient; or (2) the patient's participating doctor takes a specimen from the patient in the office (for example, blood) and sends it to a non-participating laboratory or pathologist; or (3) for any other health care services when referrals are required under the patient's plan.
- Assignment of Benefits Form. When your patient signs an assignment of benefits form for a surprise bill, your patient will only be responsible to pay you the in-network cost-sharing. You are required to hold your patient harmless for any amounts in excess of your patient's in-network cost-sharing and your patient's health plan will pay you directly for the services. The health plan is required to pay you the billed amount or attempt to negotiate reimbursement with you. If attempts to negotiate do not result in a resolution of the payment dispute, the health plan will pay you an amount that it determines is reasonable. You may dispute the amount that the health plan pays you through the independent dispute resolution process.
- When You Bill A Patient. If you are a doctor and are billing a patient for what could be a surprise bill, you are required to include an assignment of benefits form and a claim form for a third party payor with the patient's bill.
To submit a dispute, health care providers must log onto the DFS portal to obtain a tracking number:
- Complete the IDR Provider and Insurer Application; and
- Send the application to the assigned Independent Dispute Resolution entity.
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 $683.22 (adjusted annually for inflation rates) or less after any applicable co-insurance, co-payment and deductible.
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.
- 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.
Disputes involving a Patient who is not an Insured.
- 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.
If you have questions or need help completing an application, call (800) 342-3736 or email [email protected].