• New York Law - Emergency Medical Services and Surprise Bills
  • April 13, 2015 | Authors: Mark A. Cunningham; Jed Roebuck
  • Law Firm: Chambliss, Bahner & Stophel, P.C. - Chattanooga Office
  • A recent law passed in New York State may have a significant impact on the medical billing industry and could pave the way for similar laws across the country. The Emergency Medical Services and Surprise Bills Law (the "New Law") which goes into effect on March 31, 2015, aims to protect patients from "surprise bills" following treatment from out-of-network providers. Numerous complaints sent to the NY Attorney General's Health Care Bureau prompted the New Law, which is intended as a consumer protection measure.

    The New Law will primarily affect providers who balance bill their patients for out-of-networks services. Those providers will be the first to encounter New York's revised reimbursement process for what it terms a "surprise bill." A medical bill will be considered a surprise bill if:
    • the patient receives services from an out-of-network physician at an in-network hospital when an in-network physician is not available
    • an out-of-network physician administers care without the patient's knowledge
    • unexpected care is needed when services are already being administered
    • a patient is referred to an out-of-network provider by an in-network physician and the patient has not provided written consent acknowledging the uncovered costs
    • an out-of-network provider treats the patient during a visit with an in-network physician
    • an in-network physician sends a patient's specimen to an out-of-network lab or pathologist
    • there are any other health care services provided when referrals are required under the patient's plan
    A provider billing a patient in any of the above scenarios must include, along with the medical bill appropriate documentation that, once completed, enables the provider to seek payment directly from the insurer. Patients who complete this process will only be responsible for their in-network copay, coinsurance or deductible. If issues arise later between the provider and the insurer while negotiating the provider's fee, the New Law directs that the dispute be referred to the state's newly established Independent Dispute Resolution Process" (IDRP).

    Providers and insurers must also negotiate out-of-network emergency service fees directly, as insured-patients are only required to pay their in-network copayments, coinsurance, or deductibles. Insurers are instructed to reimburse providers at "appropriate" rates for their emergency services, and any resulting disputes will be referred to the IDRP.

    From a billing perspective, the most problematic portions of the New Law are likely to be the apparent grant of authority to insurers to reimburse providers at rates they deem appropriate, and the potential additional expenses and delays associated with disputing those rates through the IDRP. While the New Law may only be a test case, medical billing companies and revenue cycle management companies operating in New York should evaluate the extent to which their clients are participating or nonparticipating providers and consider the repercussions of the New Law on their ability to operate profitably in New York.