No More Surprises – NY Surprise Medical Bill Law

No More Surprises – NY Surprise Medical Bill Law

by | Mar 24, 2015 | Health Care Reform, Hospitals, NY News

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!

Resource:

NYS – Protection from Surprise Bills and Emergency Services

 

 

Patients Waking Up To Major Colonoscopy Bill

Patients Waking Up To Major Colonoscopy Bill

by | May 30, 2012 | healthcare, Hospitals

Patients Waking Up To Major Colonoscopy Bill

The NYT article  – Waking Up to Major Colonoscopy Bills illustartes what our clients are increasingly running into – increased out of pocket expenses.

“Patients who undergo colonoscopy usually receive anesthesia of some sort in order to “sleep” through the procedure. But as one Long Island couple discovered recently, it can be a very expensive nap. Both husband and wife selected gastroenterologists who participated in their insurance plan to perform their cancer screenings. … And in both cases, the Gastroenterologists were assisted in the procedure by anesthesiologists who were not covered by the couple’s insurance. They billed the couple’s insurance at rates far higher than any plan would reimburse — two to four times as high, experts say.”

Patients can go for Colonoscopies either  in an outpatient medical office or in ambulatory hospital setting.   Gastrointerologists cannot bill for the anesthesia unless there is an employed licensed Anesthesiologist on staff.  The treating Physician cannot be the same person who administer/monitors the sedation. Generally speaking the Anesthesiologist in a hospital settings are separate entities and attempt to bill independently form the hospital charges. Now you can begin to see how patients are getting  added billing.

Furthermore, we are seeing increasing  out of network charges with Physicians dropping health plans in certain geographic areas as well as insurers shifting more of the costs burden.

The posting Out of Control Out of Network Charges points to examples such as – “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.

Our clients get 3 bills with any procedure needing general anesthesia

1)   A bill from the hospital

2)  A bill from the surgeon

3)  A bill from anesthesia

Actually, the physician bill is typically the lowest cost of the bill .  On a $5,000 total bill the GI may only get 10%.  Sometimes the hospital and anesthesia charges are bundled into a single bill but many times they are not.  On most plans patients can negotiate with the hospital depending on pre-authorization the anesthesia bill and resubmit charges.  This is probably the most common appeal we perform on behalf of our clients.

Patient on a cost sharing plan with in-network deductibles may fair better  with outpatient office colonoscopies.  From an insurer costs perspective the charges in an office setting are typically $2,000-$2,500.  So why do it in the hospital? The procedure may require general anesthesia and financial incentives. Also, at times the procedure may be a loss to the provider.  For example, Pediatricians  will not perform Gardasil vaccination because the vaccine costs more than what the pediatrician will get reimbursed to give it.

The vast majority of providers make sure that  patients were in-network or arranged pre-payment plan prior to the procedure.  As with most non-HMO plans, however, the responsibility rests with patient to make sure everything is pre-authorized and in network is possible.