COMPLIANCE UPDATES – MAY 2015

By Becky Amann, Compliance Manager

Practicefirst sent out an Urgent Notice to our clients on April 17th    regarding the New York State Surprise Bill Law. The following is a recap of that notification:

NEW YORK STATE LEGISLATION – EMERGENCY SERVICES AND SURPRISE BILL LAW effective 3/31/15

New legislation has been passed by New York State, commonly known as the Emergency Services and Surprise Bill Law.  This new law went into effect on March 31, 2015.

Under the terms of this new law, patients can dispute out-of-network (OON) charges if they did not have, or were not given, the opportunity to avoid OON charges. The law applies to physicians, hospitals, insurance carriers and other facilities.

Below is a brief summary of the new law and how it may affect your practice.

Health Care Professional and Physician Disclosure Requirements:

When scheduling appointments, the following information is required to be disclosed to patients or prospective patients:

  • The names of health insurance plans with which you participate and the names of hospitals with which you are affiliated.
    • These can be provided in writing or through a website before a patient receives non-emergency services and verbally when the appointment is scheduled.
  • Notify patients that the estimated charge for a non-emergency service is available upon request if the physician does not participate with the patient’s health plan (must include disclaimer that actual charges could be higher due to unforeseen medical circumstances).

When referring or coordinating care with another provider, all health care professionals must:

  • Referrals (Coordinating Care): Disclose to patients and prospective patients the names and contact information of the providers for whom they are referring the patient to.
  • Concerning scheduled hospital admissions or scheduled outpatient hospital services:  Disclose to patients and the hospital, the names and contact information of physicians who are scheduled to treat a patient for non-emergency services during a scheduled hospital admission or outpatient hospital services.

Under this new law, patients have been given the right to dispute a “surprise” bill when it has been processed out-of-network. The patient disputes the bill by completing a Surprise Medical Bill Assignment of Benefits Form.  A copy of this form is attached. If the patient completes and forwards the Assignment of Benefits form to a provider, they cannot hold the patient responsible for the surprise bill in excess of the their  in-network copay, co-insurance or deductible. The patient’s health plan is required to pay you the billed amount or attempt to negotiate reimbursement with you. If negotiations between the health plan and you fail, either party can submit a dispute to an Independent Dispute Resolution (IDR) entity.

Per the Department of Financial Service’s website, some examples of a surprise bill are:

  • Services rendered by a non-participating physician at a participating hospital or ambulatory surgical center when: a participating physician was unavailable, or a non-participating physician renders services without the patient’s knowledge, or unforeseen medical services arise at the time the health care services are rendered.
  • Services referred by a participating physician to a non-participating provider without the explicit written consent of the patient acknowledging that the services would be out-of-network and result in cost not covered by the patient’s health plan.
  • Consultation services provided by a specialist who does not participate with the insured’s health plan when the following occurs:
    • a patient is admitted to a participating hospital following emergency services
    • a patient is admitted to a participating hospital for a scheduled hospital admission

AND a participating physician is unavailable or a non-participating physician renders services without the insured’s knowledge or unforeseen medical services arise at the time the health care services are rendered.

Conversely, some examples of bills that are not surprise bills include, but are not limited to:

  • An insured’s contract does not require the insured to obtain a referral before obtaining services. A participating physician provides the insured with a list of local laboratories and recommends that the insured make an appointment to have blood work done.
  • An insured requests a referral or authorization to a non-participating provider, the referral or authorization is denied by the health plan, and the insured subsequently obtains the services of the non-participating provider.

Emergency Services

  • The Affordable Care Act requires a health plan to reimburse out-of-network emergency services based on certain criteria.
  • A non-participating physician may dispute the amount that the health plan pays you for emergency services through the Independent Dispute Resolution (IDR) process.
  • The dispute resolution process does not apply to health care services, including emergency services, when physician fees are subject to Worker’s Comp, No Fault, Medicare fee schedules or Medicaid fee-for-service.
  • This new regulation requires insurance carriers to hold harmless the insured for charges in excess of the in-network deductible, co-payments or co-insurance for out-of-network emergency services.

Further information about this new law can be found on the New York State Department of Financial Service’s website at http://www.dfs.ny.gov/insurance/ihealth.htm. Please refer to the Out-of-Network Law Guidance.

This is a complex law, interpreting how this law affects your practice can be tricky.  We do not provide legal advice, but will attempt to answer any questions you m