Law helps cut down on surprise medical bills

Column: Law helps cut down on surprise medical bills

by Westfair Online | April 28, 2015 10:11 am


A new consumer protection law went into effect April 1 in New York — the Emergency Medical Services and Surprise Bills law — which protects patients from unexpected expenses related to out-of-network and emergency medical services. The legislation creates more transparency by requiring more disclosure of how much patients can expect to pay for medical care and about providers’ and facilities’ health plan participation.

What’s a surprise bill?

Patients have been surprised plenty in the past by unexpected medical bills and unreimbursed expenses. According to the state Department of Financial Services, surprise bills occur when services are performed by a nonparticipating (out-of-network) doctor at a participating hospital or ambulatory surgical center in the patient’s HMO or insurer’s network, or when a participating doctor refers an insured to a nonparticipating provider. The new law also protects all consumers from bills for emergency services. Full details about surprise bills, how to avoid them and how to dispute them are available at

The new law aims to eradicate these unexpected charges that arise in certain situations such as:

  1. Services rendered by a nonparticipating physician at a participating hospital or ambulatory surgical center. Situations include when a participating physician is unavailable, a nonparticipating physician renders services without the insured’s knowledge or unforeseen medical services arise at the time the health care services are rendered. It is not a surprise bill if you chose to receive services from a nonparticipating doctor instead of from an available participating doctor.
  2. Services rendered by a nonparticipating provider without explicit acknowledgment and consent from the insured. In this case, the services were referred by a participating physician to a nonparticipating provider; the insured patient did not give explicit written consent acknowledging this referral and the referral results in costs not covered by the health care plan.
  3. Uninsured for services. A patient who is not an insured for services rendered by a physician at a hospital or ambulatory surgical center has not received all the disclosures required pursuant to Section 24 of the public health law in a timely manner.

Several provisions of the law affect health insurance plans.

  • All health plans must hold patients harmless for emergency services (except for in-network cost-share). In essence, all emergency services must be treated as in-network care.
  • Plans that offer out-of-network coverage must make available one product that bases reimbursement on the “usual and customary” rate.
  • Disclosure is required for nonemergency services from health plans, physicians, health care professionals and hospitals.
  • An independent entity has been established to resolve disputes over physician fees and plan reimbursement for emergency and surprise bills.

New disclosures help avoid financial distress

Hospitals and health care providers must include a lot of new information on their websites so the public has easy access to these disclosures.

For hospitals/facilities these include health plan participation; statements that in-hospital physician services are not included in hospital charges (a common point of confusion) and that physicians/providers might not participate in the same plans as the hospital (another confusing issue); and an advisory to determine the practitioner’s plan participation in advance. Hospitals must post the contact information of the physician groups they contract with and instructions on how to contact them.

Medical providers must clearly state:

  • The names of their participating health plans (in writing or on the provider’s website and verbally when an appointment is scheduled);
  • The names of the physician’s hospital affiliations (same manner as above);
  • For nonemergency services, that the amount or estimated amount for the service is available upon request; and
  • Upon receipt of a request, the amount or estimated amount that will be billed — excepting any unforeseen medical circumstances that may arise when the services are provided (this information must be disclosed in writing).
  • The name, practice name, address and phone number of any provider scheduled to perform anesthesiology, laboratory, pathology, radiology or assistant surgeon services in connection with care provided in the physician’s office or referred or coordinated by the physician for the patient;
  • Similarly, for patients scheduled either for hospital admission or outpatient hospital service, the name, practice name, address and phone number of any other physician whose services will be arranged by the physician and are scheduled at the time of the preadmission testing, registration or admission, or at the time the nonemergency services are scheduled;
  • Additionally, information as to how to determine the health care plans in which the physician participates, and how to determine this in a timely manner.

There are many more stipulations now in place to protect consumers from unforeseen medical expenses. Anyone who receives a surprise bill for health care services and wants the services to be treated as in-network can fill out a New York State Out-of-Network Surprise Medical Bill Assignment of Benefits Form to dispute certain denied out-of-network or emergency care reimbursements. You can also work with an independent medical insurance advocate to resolve insurance issues on your behalf and recoup medical reimbursements you are entitled to according to your health plan and the law.

Adria Gross is the founder and president of MedWise Insurance Advocacy, a division of MedWise Billing Inc., based in Monroe. She can be reached at 845-238-2532 or

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