The New York State "No Surprise" Medical Billing Law - To Avoid Being Surprised, Read This

On March 31, 2015, the new "Emergency Medical Services and Surprise Billing" Act goes into effect, with implications for insurers, hospitals, physicians and patients across the state.  The intent of the Act is to protect patients from (sometimes catastrophic) financial responsibility for out-of-network emergency care and to ensure that prior to elective care there is adequate disclosure of the patient's potential out-of-network responsibility.  

Here is what physicians and other healthcare providers will need to do to comply with this legislation, according to attorneys at Nixon Peabody, a NY healthcare firm:

• Prior to providing non-emergency services, providers must disclose to patients their right 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 provide patients with their network and hospital affiliations in writing or online.
• When patients make appointments, providers must indicate whether they participate in a patient’s network.
• If other professionals will be involved in a patient’s care, the patient must be advised of who it might include and how to learn how much the network will cover for those doctors.

But the most important provisions of the law place significant limits on the physician's ability to seek out-of-network payment for emergency services. The Surprise Bill Law provides new protections for consumers from “surprise” bills for emergency medical services. For example, consumers who receive emergency services will not have to pay more than their usual in-network cost sharing and/or copayments, regardless of the network status of the providers. 

This means, for example, that a plastic surgeon who repairs a laceration in the ED will be prohibited from billing the patient for the difference between the patient's out-of-network benefit and the surgeon's usual charges.  Instead, the practitioner will have the choice of accepting the insurer's rate or submitting the matter to an independent review process that is outlined in the law.

Finally, consumers who receive other out-of-network medical services when there were no in-network providers available or when they did not receive the disclosures required by this new law can assign their claims to the out-of-network providers and pay only their usual in-network cost-sharing. In both of these situations, the medical bill is negotiated by and between the provider and the health plan. 

There are additional implications for payers, hospitals and patients.  If you are interested in reading more, go to…

http://www.nixonpeabody.com/files/169463_Health_Alert_3JUNE2014.pdf

NSLIJ HealthPort will update guidance for physicians in the near future.