written by Michael Glass
An increasingly problematic issue patients are facing lately in the medical field is the unpleasant surprise of a stratospheric bill after treatment in the emergency room or the hospital, when they were under the impression that their health insurance was covering those bills fully. In recent years, more and more doctors and hospitals are insisting payment on (and even suing their patients for) the difference between what they charge for their services, and what the patient’s insurance carrier is willing to pay.
For example, one of our clients recently had an orthopedist assigned to her in the emergency room of a local hospital to treat a badly fractured ankle. The orthopedist kept her overnight in the hospital, and performed surgery the next morning. She was well insured, and her insurance paid his bill; which should have been the end of things. But a few weeks later our client received a medical charge from his office in the amount of $27,000.00. At no time during his treatment of her, did he indicate that there would be charges over and above what her health insurance paid for.
Thankfully, help has arrived. On April 1, 2015 New York’s newly minted Emergency Room Medical Services and Surprise Bill became law in the State of New York. The law requires new disclosures from healthcare providers regarding their insurance plan participation and adds new rules for health plans regarding reimbursement for out-of-network services.
One of the most important parts of the law requires physicians, diagnostic and treatment centers and health centers to disclose the insurance plans they accept and the names of the hospitals with which the doctor or provider is affiliated. More important, doctors and facilities have to provide the amount or estimated amount of the charges for the service being performed before the provision of non-emergency services. Upon receiving a request for the amount of the charges, the estimated amount that will be billed, absent unforeseen medical circumstances, must be disclosed in writing.
One particular nasty problem we’ve seen, was that the diligent patient who made certain that the surgeon was on his or her insurance plan could, nonetheless, be surprised by an out of network service provider who provided ancillary services for the surgery or procedure, such as anesthesiology, pathology, laboratory services, or radiology services. Or even an assistant surgeon who participated in the surgery. Now, physicians must disclose to patients the name, practice name, address and phone number of any of these providers at the time that the physician decides he is going to use those additional providers.
With respect to hospitals, the law demands that the hospital post on its website a list of the hospital’s standard charges for items and services provided, and remind patients that physician services provided in the hospital may not be included in the hospital bill, and the hospital must also tell patients that a particular physician may not participate in the same healthcare plan as the hospital.
Under the new law, the patient’s insurance company or HMO also has to make certain disclosures relating to out-of-network reimbursement. Specifically, they have to note on their website information that will permit patients to determine anticipated out-of-pocket costs for out-of-network healthcare services.
Other aspects of the bill specifically hamstring physicians who would otherwise “surprise bill” patients for non-emergency services. For example, if a physician know a patient is insured and accepts an assignment of benefits from a patient’s insurance company, even if that physician is not in the patient’s insurance network, the physician cannot bill the patient for more than the amount that the patient would have paid if the service was provided in-network. Physicians may bill an insured patient if no assignment of benefits was made, but the patient may take the bill to binding arbitration before owing any amount.
The new law addresses important loopholes, which previously permitted physicians and healthcare providers to surprise bill patients for thousands of dollars of unanticipated medical charges. If you have any questions regarding the new law, contact RGLZ Personal Injury Law at 1-800-734-9445.