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Surprise Medical Bills

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Surprise Medical Bills and Emergency Services

The law protects you from surprise bills and bills for emergency services. Consumers in New York are protected from surprise bills when treated by a non-participating (out-of-network) doctor at a participating hospital or ambulatory surgical center in their health plan’s network. Additionally, consumers with health insurance coverage provided by an insurer or HMO are protected from surprise bills when a participating doctor refers them to a non-participating provider. Consumers in New York are also protected from bills for emergency services in hospitals, including inpatient care following emergency room treatment.

The following information explains what you need to know about these important 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.

Surprise Medical Bills - How to Protect Yourself if You Have HMO or Insurance Coverage Subject to NY Law (not self-insured)

When You Receive Services From A Non-Participating Doctor At A Participating Hospital Or Ambulatory Surgical Center, It’s a Surprise Bill If:

  • A participating doctor was not available; OR
  • A non-participating doctor provided services without your knowledge; OR
  • Unforeseen medical services were provided when you received health care services.
  • It is not 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, It’s A Surprise Bill If:

  • You did not sign a written consent that you knew the services were out-of-network and would not be covered by your health plan; AND
    • During 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. You will be protected from a surprise bill and you will only have to pay your in-network copayment, coinsurance, or deductible if you:

  • Sign AOB Form.Sign an Assignment Of Benefits form to allow your provider to seek payment from your health plan; AND
  • Send AOB Form and Bill. Send the assignment of benefits form to your health plan and provider and include a copy of the bill you do not think you should pay.

Surprise Medical Bills - How to Protect Yourself if You Are Uninsured or Have Employer/Union Self-Insured Coverage

When You Receive Services At A Hospital or Ambulatory Surgical Center. If you are uninsured or your employer or union self-insures, you may file a dispute through the independent dispute resolution (IDR) process if you receive a surprise bill from a doctor for treatment at a hospital or ambulatory surgical center and the doctor did not give you the required information about your care. You will have to pay the fee for the IDR if your doctor’s bill is upheld unless your household income is below 250% of the Federal Poverty Level. See Information Your Doctor And Other Health Care Providers Must Give You and Information Your Hospital Must Give You for a list of the information that must be provided to you.

Application. Complete an IDR Patient Application and send it to NYS Department of Financial Services, Consumer Assistance Unit/IDR Process, One Commerce Plaza, Albany, NY 12257. IDR Patient Application (PDF)

Emergency Services - How to Protect Yourself if You Have HMO or Insurance Coverage Subject to NY Law (not self-insured)

Health Plans Must Hold Insureds Harmless. 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, or for inpatient services that follow an emergency room visit, that are more than your in-network co-payment, coinsurance, or deductible. Let your health plan know if you receive a bill from a non-participating provider for emergency services.

Providers Must Hold Insureds Harmless Who Sign An AOB. Your provider will only bill you for your in-network copayment, coinsurance, or deductible for emergency services, including inpatient services which follow an emergency room visit, if you have coverage through an HMO or insurer subject to NY law (coverage that is not self-insured) and you:

  • Sign AOB Form. Sign an Assignment Of Benefits form to allow your provider to request payment from your health plan; AND
  • Send AOB Form and Bill. Send the assignment of benefits form to your health plan and provider and include a copy of the bill you do not think you should pay.

Emergency Services - How to Protect Yourself if You Are Uninsured or Have Employer/Union Self-insured Coverage

Emergency Services. If you are uninsured or your employer or union self-insures, you may file a dispute through the independent dispute resolution (IDR) process if you receive a bill for emergency services in New York that you believe is excessive. You will have to pay the fee for the IDR if your provider’s bill is upheld unless your household income is below 250% of the Federal Poverty Level.

Application. Complete an IDR Patient Application and send it to NYS Department of Financial Services, Consumer Assistance Unit/IDR Process, One Commerce Plaza, Albany, NY 12257.

Surprise Medical Bills - What Health Care Providers Need to Know

If your patient has coverage through an HMO or insurer subject to NY law (coverage that is not self-insured):

A Surprise Bill Is:

  • 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 must include an assignment of benefits form and a claim form for a third-party payor with the patient's bill.

Submit a dispute.

If your patient is uninsured or has coverage through an employer or union that provides self-insured coverage (that is not subject to New York law), a bill will be a surprise bill if:

Services At A Hospital or Ambulatory Surgical Center. Services are provided by a doctor at a hospital or ambulatory surgical center and the patient is not given all the required information about his or her care. See Health Care Professional and Physician Disclosure Requirements and Hospital Disclosure Requirements for a list of the information that must be provided to patients. In such cases, your patient may dispute the amount of the bill through the independent dispute resolution process.

Emergency Services Bills - What Health Care Providers Need to Know

Doctors. You may dispute the amount that the health plan pays you for emergency services, including payment for inpatient services that follow an emergency room visit, 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 $693.66 (adjusted annually for inflation rates) or less after any applicable co-insurance, co-payment and deductible.

Hospitals. You may dispute the amount that the health plan pays you for emergency services, including payment for inpatient services that follow an emergency room visit, through the independent dispute resolution process if you do not participate with a patient's health plan.

Assignment of Benefits Form. When your patient signs an assignment of benefits form for a bill for emergency services, including inpatient services which follow an emergency room visit, 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 emergency services, you should include an assignment of benefits form and a claim form for a third-party payor with the patient's bill.

Submit a dispute.

Health Care Providers to Submit a Dispute Through the Independent Dispute Resolution (IDR) Process

For health care providers to start the IDR process:

Patients to Submit a Dispute Through the Independent Dispute Resolution (IDR) Process

Uninsured Patients, or Patients With Employer or Union Self-Insured Coverage, or Insureds Who Do Not Assign Benefits for Surprise Bills.

To submit a dispute, you must complete an IDR Patient Application and send it to NYS Department of Financial Services, Consumer Assistance Unit/IDR Process, One Commerce Plaza, Albany, NY 12257.

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. Parties to the dispute must submit all necessary information with their IDR application and immediately when contacted by the IDRE, or the information will not be considered.

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;
  • In the case of a hospital, the teaching status, scope of services, and case mix;
  • The circumstances and complexity of the case;
  • Patient characteristics; and
  • For physician services, the usual and customary cost of the service.

IDRE may direct a good faith negotiation for settlement. In cases when settlement is likely, or if the health plan's payment and the provider's fee are unreasonably far apart, the IDRE may direct the parties to negotiate.

Review is Binding. The review is binding but 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 provider pays the cost of the dispute resolution when the IDRE determines that the provider’s fee is not reasonable.
  • The patient pays the cost of the dispute resolution when the IDRE determines that provider’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.

 

Questions About IDR

If you have questions about IDR or need help completing an application call (800) 342-3736 or email [email protected].