NY Passes Law to Ensure Greater Transparency in Out-of-Network Payments to Physicians

Significant changes will be introduced starting April 1, 2015 by the New York State Legislature to add a layer of protection against out-of-network billing on patients. Under this new law, health care providers will be obligated to provide patients with their plan affiliations prior to the provision of non-emergency services, and verbally at the time of the appointment. This law is known as the “Emergency Medical Services and Surprise Bills” law, the new legislation is aimed at allowing patients to go out of network, if the insurance plan’s existing network is insufficient, and will also ensure transparency of out-of-network charges and network participation. The significant features of this law are as follows. Practical Implications - Provider Disclosures:

  • Providers must provide patients with their network and hospital affiliations in writing or online (website).
  • At the time of patient appointments, providers must indicate whether they participate in the patient’s network or not.
  • Prior to providing non-emergency services, providers must disclose to the patients their rights to know what will be billed for the procedure, and if the patient requests, they must disclose the anticipated cost, warning patients that costs could go up if unanticipated complications occur.
  • Providers must inform patients, If other professionals will be involved in the patient’s care, the patient must be advised of names of such providers and how much cover will be provided by the payer versus co-insurance. This information would include - 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 to be provided in the physician’s office.
  • Practices must share provider information and their network affiliations, with the hospitals or other facilities where the services are likely to be rendered.

Note: Hospitals must now provide additional information to patients. Hospitals must:

  • Publicly post a schedule of charges for various services on their websites
  • List the health plans in which they participate.
  • Warn patients that physician services may not be covered by hospital bills and tell them how to check with physicians regarding their network affiliations.
  • Post the names of practice groups for such services as radiology, anesthesiology and pathology with which the hospital has a contract, along with information on how patients can determine the network affiliations of those groups and the individual doctors part of those groups.
  • Post information, including network affiliations, of doctors who are hospital employees (and give this information directly to patients when they register or are admitted for care).

Practical Implications - Surprise Bills:

  • Patients receiving out of network benefits in emergency will pay the regular in-network costs, i.,e  Co- insurance and or copayment amounts irrespective of the network.
  • Patients who receive out of network non-emergency services will pay the regular in-network costs., i.,e  Co- insurance and or copayment amounts irrespective of the network under the following scenarios.
    • Lack of adequate in-network physicians availability. This directly in line with a related law referred to as “network adequacy rule”, which requires “all health plans that are based on comprehensive provider networks (including PPO—preferred provider organization and EPO—exclusive provider organization plans) be certified as having provider networks that can meet the health needs of their members without having to rely on the more expensive out-of-network services”.
    • Prior to the new law, these network adequacy rules only applied to HMO.If a plan’s network does not have a geographically accessible provider with appropriate expertise to treat a patient’s medical problem, patients in all plans can seek services from an out-of-network provider without incurring the additional out-of-network expense—the patient’s health plan will pay for all expenses other than the usual in-plan copayments and cost-sharing.
    • Due to a referral received for an out-of-network provider without the proper disclosures.
    • Patients with life- threatening or seriously disabling or degenerative conditions in all health plans will have the right (where medically appropriate) to have specialists serve as their primary care doctors and to be referred to centers of excellence in treating their conditions.

Note: The disputed bill must be negotiated directly between the physician and the health plan. The patients will not be liable to do so. Practical Implications - Payer / Insurance Disclosures:

  • Payers must now update their provider network listings within 15 days after changes in physician network or hospital affiliations. This helps patients stay current in their assumptions about which providers are covered in-network.
  • When a patient seeks authorization for services by particular providers, the payer must tell patients whether those providers are in-network and what the anticipated reimbursement will be.
  • Payers must put information on their website that reasonably allows an insured to determine the anticipated out-of-pocket cost for an out-of-network healthcare service based on the difference between the amount that they will reimburse for the out-of-network health care service and the “usual and customary cost” for such out-of-network health care service.
  • Upon request of an insured or prospective insured, disclose the approximate dollar amount that the insurer will pay for an out-of-network service and that such approximation is not binding and may change.
  • Health plans that offer group coverage with out-of-network benefits are required to offer at least one plan that reimburses at 80 percent of the usual, customary and reasonable fee.
  • Group insurers are required to offer out-of-network coverage in  regions where that option has not been available.

Note: The disputed bill must be negotiated directly between the physician and the health plan. The patients will not be liable to do so. Practical Implications - Patient:

  • Physicians that accept an assignment of benefits from a patient and knows that the patient is insured may not bill that patient for more than the amount that the patient would have paid if the service was provided in-network (e.g., copay or coinsurance and applicable deductible).
  • Physicians may bill an insured patient if no assignment of benefits was made, but the patient may take the bill to binding dispute resolution before owing any amount.
  • Uninsured patients who receive medical bills without having adequate notification of the likely cost can also go to an independent review process. In that case, the IDRO will set a reasonable fee for the services the patient received, taking into account such information as what the provider charges to insured patients.
  • The independent dispute resolution entity will make a binding decision within 30 days. There will be no impact on the transfers to the collection agency.