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Avoiding required dispute resolution to get paid for Surprise Bills (NY Only, Effective 4/1)

March 12, 2015
Tuesday's email began our discussion about the new Surprise Law in NY as it relates to healthcare practitioner private practices (outside the hospital realm and emergency services) - which requires certain disclosures to patients to avoid a surprise bill for services rendered as of April 1, 2015.  We discussed having policies adopted in order to adhere to those certain required disclosures (available here, see OON Disclosure Forms).

Included in the relevant statutes is an independent dispute resolution process for any Surprise Bill.  To reiterate from Tuesday, a Surprise Bill is defined as a bill for health care services received by an insured for services rendered: (1) by an out of network provider at a participating hospital or ASC where a participating physician was not available or the out of network provider rendered services without the insured’s knowledge, or unforeseen medical services arise at the time the health care services are rendered, except where insured elects out of network provider; (2) where patient has not given explicit written consent acknowledging they were referred to an out of network provider, and that the referral may result in costs not covered by their health care plan; or (3) when an uninsured patient is not provided required disclosures and is treated at a hospital or ASC.  

NY CLS Financial Services  Law s. 603
 
So what happens when a patient receives a "Surprise Bill"? As per the new law, parties are entitled to Dispute Resolution.  

For a Surprise Bill received by an insured who assigns benefits to a non-participating provider - 
  1. the health plan can pay the billed amount or attempt to negotiate a lower amount.
  2. if the health plan refuses to pay the requested amount and negotiation does not result in a resolution of the payment dispute, the health plan will pay what it wants to the provider, minus any co-payment, deductible or coinsurance.
  3. Either party may submit the dispute regarding the Surprise Bill for review to an "independent dispute resolution entity", except that a health plan cannot submit unless it has attempted to negotiate and has paid some amount it determines reasonable.
  4. The independent dispute resolution must make a determination within 30 days of receipt of the dispute for review. 
  5. The independent dispute resolution entity shall determine which fee to accept - the non-par or the health plan proposed fee. 
For a Surprise Bill received by an insured who DOES NOT assign benefits to a non-participating provider or by a patient who is NOT an insured - 
  1. The patient may submit the Surprise Bill for dispute resolution to an independent dispute resolution entity.
  2. The independent dispute resolution entity will determine a reasonable fee based on certain factors (see below).
  3. The patient doesn't have to pay the practitioner before submitting for review!
The determination by the independent dispute resolution entity shall be binding and admissible in court!

There are a number of factors the independent dispute resolution entity is instructed to consider, including:
  1. fees paid by other plans to the practitioner; 
  2. fees paid to other practitioners by the same plan;
  3. level of training, education and experience of the physician;
  4. physician's usual charge for comparable services;
  5. the circumstances and complexity of the particular case;
  6. the individual patient characteristics; and 
  7. the usual and customary cost of the service - which means the 80th percentile of all charges for the particular service performed by a provider in the same specialty provided in the same geographical area as reported in a bench-marking database maintained by a nonprofit organization specified by the superintendent of financial services. 

So, what is the bottom line here?  Avoid any "Surprise Bills" at all costs.  Rendering same will require your possible attendance to independent dispute resolution, turning reimbursement into what many of you contend with in the no-fault world, a turnstile of arbitration for reimbursement. 
 
CLICK HERE for OON Disclosure Forms.   (All orders in March 2015 will be processed at the reduced fee of $315.)
 

 

 


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