A new law impacting New York out-of-network providers, called the Emergency Services and Surprise Bill, went into effect on March 31, 2015, that will require providers to update their operations if they do not already comply with the legal requirements.
Out-of-network physicians treating insured patients (those with HMOs or insurers subject to NY Law) at hospitals or ambulatory surgical centers for an emergency will now have to submit a claim for reimbursement to the patient’s insurer. The insurer will reimburse the physician an amount the insurer deems reasonable for the emergency services rendered. If physicians disagree with the reimbursed amount then their recourse is the dispute resolution mechanism with the independent dispute resolution (IDR) entity. Patients covered by these plans may not be balanced billed by providers and are only responsible for their in-network copayment, coinsurance or deductible.
For uninsured patients (or patients with self-insured plans), either the patient or the patient’s physician may submit a dispute regarding a fee for emergency services for review to an IDR entity.
The law also defines who pays for the IDRs. In a dispute between a provider and a health plan subject to New York law, the provider pays the cost of the dispute resolution when the IDRE determines that the health plan’s payment is reasonable. When the IDRE determines that the provider’s fee is reasonable then the health plan pays the cost of the dispute resolution. Parties share the prorated cost when there is settlement.
In a dispute involving an uninsured patient, the doctor pays the cost of the dispute resolution when the IDRE determines that the doctor’s fee is not reasonable. The patient would be responsible for the cost of the dispute resolution if the determination is made in favor of the doctor unless the fee would pose a hardship to the patient.
The new law also provides consumers protection against “surprise bills” in non-emergency situations. The law identifies specific situations which would constitute a surprise bill.
Additionally, the new law has new patient disclosure requirements. The law requires that, among other things, health care professionals have to disclose to patients or prospective patients the following information: (1) health plans in which the health care professional participate with; (2) hospitals with which the health care professional is affiliated; and, (3) upon request from the patient, the amount or estimated amount that the health care professional will bill the patient for health care services, in writing (if the health care professional does not participate with a patient’s or prospective patient’s health plan). The first two requirements are required to be given in writing or through a website prior to the provision of non-emergency services and verbally at the time an appointment is scheduled.
If you are party to a billing dispute, audit or investigation, require assistance with the Emergency Services and Surprise Bill law, or have other health law related questions, please contact us here.