No More Surprises – NY Surprise Medical Bill Law

No More Surprises – NY Surprise Medical Bill Law

Emergency Bill HelpNo More Surprises – NY Surprise Medical Bill Law

Consumer complaints about receiving inadequate reimbursement from their insurers for medical services that they received outside of a provider network have been answered by New York’s “Emergency Medical Services and Surprise Bills” law. As of March 31, 2015, consumers will have protection from “surprise” medical bills for emergency medical services and certain out-of-network medical services.

The state of affairs today for small business plans offering both in and out of network is an exception with only 2 insurers in Downstate covering out of network at catastrophic high deductible levels.  For Individual Marketplace it is even more dire with NO OUT OF NETWORK coverage at all.

The Problem. This has been a pattern in recent years and posted in Out of Control Out of Network Charges (March 2012).  According to an investigation report commissioned by Governor Cuomo recognizing the unexpected out-of-network claim problem.  Officials say that this is now  “an overwhelming amount of consumer complaints.”   Some examples cited in the report An Unwelcome Surprise – “a neurosurgeon charged $159,000 for an emergency procedure for which Medicare would have paid only $8,493.”  Another example: ” a consumer went to an in-network hospital for gallbladder surgery with a participating surgeon. The consumer was not informed that a non-participating anesthesiologist would be used, and was stuck with a $1,800 bill. Providers are not currently required to disclose before they provide services whether they are in-network.” The average out-of-network radiology bill was 33 times what Medicare pays, officials say.

The blog post goes on to say “Today, 90% of SMB members have in network only benefits but the few remaining consumers are paying for eroding out of network benefits with little transparencies and necessary protection from new out of network billing practices.  The NY Dept of Financial services  is calling for providers in non-emergency situations to disclose whether or not all services are in-network, what out-of-network charges will be and how much insurers will cover.”

Balance Bill Protection.  The long awaited bill passed last April protects patients from out-of-network providers from “balance-billing” consumers for emergency care or when patients can’t choose their doctors. Balance-billing occurs when health workers who don’t accept a patient’s insurance try to collect the difference between their charge and the insurer’s reimbursement.

Provider Disclosure Requirements. Hospitals will now be required to disclose anticipated charges. Patients most often receive these surprise bills in emergency cases, when they can’t choose the doctors who treat them.  Its not unusual for a Provider to come into the picture who may read your tests or touch you thats not in network.  Under the new law all medical providers will have to notify patients before treatment if they don’t take their insurance. If not, patients will be required to pay only a regular co-pay as if the provider was in network.

Providers will need to provide patients with disclosures of the health plans with which they participate and the names of the providers that may be billing them. They are also required to disclose procedures to follow with the an independent dispute-resolution entity (IDRE) which will be the arbiter of disputes under the law  if a patient feels that a bill is inappropriate.

Network Adequacy. While the Affordable Care Act didn’t address surprise bills, the government has imposed network adequacy requirements that prevent health plans from having too few providers, which may reduce the number of cases where patients find themselves inadvertently out-of-network. New York will now require doctors and hospitals to disclose their network status before treatment in non-emergency procedures. Insurers will have to update online provider directories within 15 days of a change.

Prior to the Surprise Bill Law, these network adequacy rules only applied to health maintenance organizations (HMOs) and other “managed care” plans.   HMO’s normally have more Provider/Insurer responsibility shifting form the patient. As with most non-HMO plans, however, the responsibility rests with patient to make sure everything is pre-authorized and in network is possible.  Starting next month Health plans that are also based on more comprehensive PPO and EPO are also required to be certified as having provider networks that can meet the health needs of their members without having to rely on more expensive out-of network services.

A patient protection law is a welcome respite form the unfair unwelcome surprises out of one’s control. Common sense finally prevails!


NYS – Protection from Surprise Bills and Emergency Services