September 24, 2024 — Receiving an unexpected or “surprise” bill from an out-of-network (OON) provider can put an immense amount of stress on a patient and cause extreme financial hardships. Patients are left thinking they are responsible for substantially higher bills from an OON provider rather than if the same service was rendered with an in-network (INN) provider.
Empire Plan enrollees who receive care from a health care provider in New York have protection. Under New York State’s Surprise Bill Law, patients do not have to pay OON provider charges for surprise OON services that are higher than the patient’s standard INN copayment, deductible, or coinsurance.
This law is intended to protect patients from inadvertently receiving large bills for OON services and/or providers’ costs that were beyond the patient’s control. Provisions of the law also expand the protections currently provided to members of HMOs participating in the New York State Health Insurance Program (NYSHIP).
The law requires that physicians, hospitals, and health plans must disclose specific information to patients and protect patients who must go OON for a specialist or procedure not available within their health plan’s network.
What is a “Surprise Bill”?
A bill will be considered a “surprise bill” (according to the state Department of Financial Services (DFS)) under the following circumstances:
- If the patient was treated at any point by an OON provider without giving written consent to be treated OON
- If no INN physician was available at the time to provide care, or if an INN physician provided a referral to an OON provider without explaining that the provider was OON.
- If any emergency or unforeseen medical needs that arose over the course of a visit required the immediate attention of an OON provider.
For example, a patient could have a scheduled surgery with an INN surgeon, but be unaware that the anesthesiologist was OON or a patient having a severe cardiac event could be billed for OON care administered at the nearest hospital, even though the patient was taken to the hospital by ambulance.
Protection from “Surprise Bills”
Patients who receive a surprise bill for OON emergency services will not be required to pay more than their INN copayment/cost-sharing amount, regardless of their treating physicians network status. Similarly, patients who receive a surprise bill for OON non-emergency services will not have to pay more than their usual INN copayment/cost-sharing amount.
Billing Resolution and Independent Dispute Resolution (IDR) Process
In the event a patient receives a surprise bill, the health plan administrator will make a payment to the provider. If the provider believes the amount is incorrect or too low, the plan and provider go through the IDR process to determine the final amount to be paid. The patient is not held responsible as long as the care/services received are in line with the surprise billing circumstances outlined within the law.
If you believe you have received a surprise bill, please complete the Surprise Bill Certification Form here and submit a copy to your health plan administrator along with a copy to your provider’s office. The health plan will review your inquiry to ensure that the bill in question meets the New York State definition of a surprise bill and will work with your provider regarding payment.
If the surprise bill is covered under the Surprise Bill Law, the health plan will work with the provider to resolve the bill, and a surprise bill adjustment amount will appear on your next monthly health statement or explanation of benefits (EOB) after it has been processed. If the surprise bill is not covered under the Surprise Bill Law, you will be notified of the denial and will be responsible for any costs not covered under your contract.
Network
If an Empire Plan enrollee does not have reasonable access to an INN physician, the enrollee can receive services from an OON physician at the INN level of benefits. This is called the Guaranteed Access Program (GAP). If you need assistance with finding a provider, please call United HealthCare (UHC) at 1-877-769-7447 to discuss the GAP before utilizing an OON provider or seeking OON services.
Additional Information
For more detailed information, call the DFS at 1-800-342-3736 or visit the DFS website. You may also wish to learn about the Federal No Surprises Act. And if necessary, you may file a complaint with DFS.