On April 1, New York State implemented new legislation that protects patients from "surprise bills" that may result from out of network physicians providing services to the patient without the patient's specific consent to being treated by an OON physician.
This often arises in an in-network hospital admission or emergency room visit. With this law coming into effect, new disclosure requirements regarding plan participation and updated billing and reimbursement policies have been put in place. It is critical for providers to fully understand what is required so they can create a strategic action plan and remain compliant under the changed medical landscape.
Disclosure requirements
In a non-emergent situation, under the new law, if services will be provided by an OON physician, all physicians must share with current and prospective patients the name and contact information for any medical professionals that will participate in procedures taking place in the physician's office or coordinated/referred by the physician. This includes anesthesiologists, radiologists and pathologists as well as those providing any additional assistant surgery services.
Patients scheduled for outpatient service or admission to a hospital must be provided the name and contact information for any medical professionals participating in the procedure/service. Additionally, physicians must share information on how the patient can find what health plans the medical professionals participate in prior to the patient's admission.
Professional medical groups, health and treatment centers must disclose in writing or on their website all health plans they participate in, as well as all hospitals they are affiliated with (this must also be shared verbally upon an appointment being made). Prior to providing non-emergency services, providers must inform all patients that the amount or estimated amount of service is available upon request. The proposed fee must then be disclosed in writing with a warning that costs could go up if unanticipated complications occur.
Billing and reimbursements
Under the new law, patients who receive OON emergency services will not be required to pay more than their usual in-network cost sharing and/or co-payment amounts, regardless of the network status of their treating physician. Similarly, patients who receive OON non-emergency services (because there were no adequate in-network physicians available, or because they received a referral to an OON provider without the proper pre-treatment disclosures) will not have to pay more than their usual in-network co-pay/cost-sharing.
Dispute resolution process
A new independent dispute resolution process has been established to reconcile bills for emergency services from OON physicians and other "surprise bills." The new IDR process takes the patient out of the equation and leaves it up to the insurer and physician to arrive at a satisfactory payment arrangement despite the fact that the physician is OON and has no contractual relationship with the insurer.
New York State's "Surprise Bills" law has adjusted the care and financial landscape of medical services. It is imperative that physicians, health and treatment centers are educated on the new legislation and that all necessary procedures are put in place to ensure there are no legal and/or financial ramifications moving forward.
Gary S. Sastow is a partner at Brown, Gruttadaro, Gaujean & Prato, LLC in White Plains, New York, and has over twenty years of experience in the practice of law, with a focus on representing healthcare professionals in all aspects of their business. Having been raised in a family of physicians, he possesses a unique understanding and insight into the business of practicing medicine. Mr. Sastow is a prolific speaker, author of professional articles and serves as an adjunct professor at Pace University where he teaches courses in Health Law and Policy and Not for Profit Organizations.
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