Is Balance Billing Legal in New York State Explained Simply

In New York State, balance billing is a bit of a gray area, but let's break it down simply.

Balance billing, also known as surprise billing, happens when a healthcare provider charges you more than what your insurance covers. This is often the case when you receive care from an out-of-network provider.

New York State has laws in place to protect patients from surprise medical bills, but there are some exceptions.

The state's "Surprise Medical Bills" law aims to prevent balance billing in most cases, but it's not a guarantee that you won't receive a surprise bill.

In New York, patients have certain protections against balance billing. You only have to pay your in-network cost-sharing for bills from out-of-network emergency services in a hospital.

The Federal No Surprises Act requires providers to make certain disclosures regarding balance billing protections. These disclosures include postings on provider websites, notices provided directly to patients, and signage at provider locations.

If you receive a bill from an out-of-network provider for emergency services, you may only be responsible for paying your in-network cost-sharing. You should let your health plan know if you receive such a bill.

Out-of-network providers rendering post-stabilization services to patients with self-funded coverage may be permitted to waive balance billing protections if the conditions for waiver, including the NSA’s notice-and-consent procedure, are satisfied.

If you are uninsured, you may file a dispute through the New York State independent dispute resolution (IDR) process if you receive a bill for emergency services that you believe is excessive. You will have to pay the fee for the IDR (up to $395) if your provider’s bill is upheld unless your household income is below 250% of the Federal Poverty Level.

DFS has developed a model notice that incorporates New York Surprise Billing Law protections into the federal model notice. This notice must provide information about both Federal and New York state balance billing protections.

Here are some key facts about balance billing protections in New York:

In New York, there are specific protections against balance billing, which is when a healthcare provider charges a patient more than the allowed amount for out-of-network services.

The No Surprises Act (NSA) requires providers to make certain disclosures about balance billing protections, including postings on their websites, notices to patients, and signage at their locations. These disclosures must include information about both federal and New York state balance billing protections.

New York state balance billing protections are more comprehensive than the federal law, and providers are required to follow both sets of rules.

To waive balance billing protections, patients must sign a written consent acknowledging that the services would be out-of-network and would result in costs not covered by their health plan.

Out-of-network providers rendering post-stabilization services to patients with self-funded coverage can waive balance billing protections if the conditions for waiver are satisfied, including the NSA's notice-and-consent procedure.

The NSA allows patients to waive balance billing protections for bills from non-participating providers at in-network facilities for non-ancillary services when the NSA's notice-and-consent procedure is followed.

However, the New York Surprise Bill Law does not permit waiver of these balance billing protections with respect to "surprise bills", which are defined as bills for services when a participating physician is available but the patient elects to receive services from a non-participating physician.

To avoid being considered a surprise bill, patients must have at least 72 hours' notice of availability of a participating physician for a subsequent bill from a non-participating physician.

Here are the key takeaways about balance billing protections in New York:

Independent dispute resolution (IDR) is a process that helps resolve disputes between healthcare providers and health plans over surprise medical bills. The IDR process is binding, meaning the decision made is final and can be used in court if necessary.

The IDR process involves an independent dispute resolution entity (IDRE) that reviews the dispute and makes a determination within 30 days. The IDRE considers factors such as the provider's training and experience, the usual and customary cost of the service, and the circumstances and complexity of the case.

Here are the factors the IDRE considers when making a determination:

In some cases, the IDRE may direct a good faith negotiation for settlement if the health plan's payment and the provider's fee are unreasonably far apart.

The cost of the IDR process is typically borne by the party that loses the dispute. If a provider and a health plan reach a settlement, they may share the prorated cost of the IDR process.

Surprise medical bills can be a major financial burden for patients. They occur when a patient receives unexpected medical bills from out-of-network providers, often for services that were not disclosed beforehand.

In New York, consumers are protected from surprise bills when treated by an out-of-network provider at a participating hospital or ambulatory surgical center in their health plan's network. This protection also applies when a participating doctor refers a patient to a non-participating provider.

Consumers in New York are also protected from bills for emergency services in hospitals, including inpatient care following emergency room treatment. This protection ensures that patients are not held financially responsible for unexpected medical expenses.

If you have coverage with an HMO or insurer subject to New York law, you are protected from surprise medical bills. However, if you are uninsured or have self-insured coverage that is not subject to New York law, you may not be protected.

The New York Surprise Bill Law defines a "surprise bill" as a bill for services that were not disclosed beforehand, including circumstances where a participating physician is available but the patient elects to receive services from a non-participating physician. To be considered a surprise bill, patients must not have been provided with at least 72 hours' notice of availability of a participating physician.

Here are some key facts about surprise medical bills in New York:

In New York, state law prohibits balance billing for emergency services. This means that patients cannot be charged more than the in-network cost-sharing amount for emergency care, even if the provider is out-of-network.

The New York State Department of Financial Services has rules in place to regulate balance billing practices. These rules require health insurance companies to cover emergency services from out-of-network providers without charging patients more than the in-network cost.

New York State law also requires hospitals to provide patients with information about their rights and responsibilities regarding balance billing. This includes informing patients that they cannot be charged more than the in-network cost for emergency services.

The New York State Department of Financial Services has the authority to investigate complaints about balance billing and take enforcement action if necessary. This includes fines and penalties for health insurance companies that fail to comply with state regulations.

New York State law also provides a process for patients to dispute balance bills and seek reimbursement for overcharges. Patients can file a complaint with the New York State Department of Financial Services or seek assistance from a consumer protection agency.

In New York, patients have the right to receive an estimate of costs before undergoing a medical procedure.

The New York State Department of Financial Services requires health insurers to provide patients with a clear and concise estimate of their out-of-pocket costs.

Out-of-network providers are not required to provide patients with a good faith estimate of costs, but they must still provide an estimate.

New York law requires that patients be informed of their right to receive an estimate of costs before undergoing a medical procedure.

If a patient receives a surprise medical bill, they should contact their insurance company to report the issue and ask for help resolving it.

Disputes involving health plans are reviewed by an independent dispute resolution entity (IDRE) within 30 days of receipt of the dispute.

The IDRE will make a determination by choosing either the out-of-network provider's bill or the health plan's payment for disputes involving health plans.

For disputes submitted by uninsured patients, the IDRE determines the fee.

The IDRE considers factors like gross disparity between the provider's fee and fees paid to other patients, the provider's training and experience, and patient characteristics when making a determination.

The IDRE may direct a good faith negotiation for settlement if the health plan's payment and the provider's fee are unreasonably far apart.

The review is binding but admissible in court.

Here's a breakdown of who pays the cost of dispute resolution:

Surprise medical bills can contribute significantly to financial burden and medical debt among insured individuals, though data on the incidence and impact of this problem are limited.

Federal authority to track the incidence and impact of surprise medical bills exists but has not yet been implemented. This lack of data makes it harder for consumers to take action to avoid surprise medical bill situations.

The problem of surprise medical bills is likely to continue, and may increase to the extent plans create narrower provider networks. This means that consumers will be hard pressed to avoid surprise medical bill situations absent intervention by policy makers.

A Kaiser Family Foundation report on medical debt featured one patient who had surgery and follow-up rehab services at an in-network hospital, only to learn that the rehab floor was operated by an out-of-network subcontractor. This highlights the complexity of surprise medical bills.

Transparency reporting requirements for non-Marketplace plans under Section 2715A of the ACA had an effective date of September 23, 2010, while requirements for Marketplace plans under Section 1311(e) had an effective date of January 1, 2014. These requirements aim to provide more transparency in healthcare costs.

Non-participating Medicare providers can decide on a service-by-service basis whether to accept Medicare assignment and forego balance billing. This means that some providers may still charge Medicare beneficiaries for services.

Here are some key statistics on the impact of balance billing:

Arbitration, or independent dispute resolution, is used in New York's balance billing law to resolve disputes between patients and providers. However, the guidance given to arbiters may lead to higher prices being set.