Dispute a Surprise Medical Bill

You can submit a dispute through the Independent Dispute Resolution (IDR) process for surprise bills or emergency services.


What To Do If You Receive 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:

1. Sign AOB Form. Sign an Assignment Of Benefits Form to allow your provider to seek payment for the bill from your health plan.

2. 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 or Self-Insured Patient Dispute

Uninsured patients, patients with employer or union self-insured coverage, or insureds who do not assign benefits who wish to submit a dispute, must complete an IDR Patient Application and send it to:

New York State Department of Financial Services
Consumer Assistance Unit/IDR Process
One Commerce Plaza, Albany, NY 12257


Insurer and Provider Disputes

Physicians or insurers submitting a dispute involving an insured patient must log onto the DFS portal to obtain a tracking number:


Review of Surprise Bills by IDRE

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 Disputes

Disputes between a provider and a health plan, involving an insured patient:
  • Provider pays the cost 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.
  • provider or health plan may incur a minimal fee if a submitted dispute is found ineligible or incomplete.
Disputes involving a patient who is not Insured:
  • Doctor pays the cost of the dispute resolution when the IDRE determines that the doctor's fee is not reasonable.
  • 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.


Learn More About Surprise Medical Bills

To learn more about surprise medical bills, visit our Health Insurance Resource Center section on Surprise Medical Bills.


Questions?

If you have questions or need help, call (800) 342-3736 or email [email protected].