New Yorkers were protected from $400,000,000 in unfair, out-of-network bills between 2015 and 2018 because of our surprise bill law. New York passed the law in 2015 after the state received hundreds of complaints over the years from people who had done everything they could to use in-network providers, but still ended up with huge bills.
The law is especially effective for people being billed for emergency services. Providers cannot bill patients for out-of-network emergency services that the patient could not avoid. Neither the provider nor the plan may charge patients for services in excess of the deductible, copay, or coinsurance amounts they owe according to their plan agreement. Patients are also protected in non-emergency situations when they are at an in-network hospital or ambulatory center and there is no in-network physician available, they are taken care of by an out-of-network provider without their knowledge, or an unforeseen medical issue arose that required unplanned medical care.
The patients’ insurance company and the provider have to figure it out without involving the patient whatsoever. In New York they do that through a third-party in a process called independent dispute resolution (similar to baseball arbitration). The law not only helps patients avoid unfair bills, it helps keep insurance premiums down because the dispute resolution process prevents insurers from having to pay excessive charges. And now that this process is in place, providers working in hospitals have more incentive to join insurance networks and work out a system of payment through a regular network agreement. That means fewer surprise bills overall.
Our surprise bill law is missing some pieces. One of the most common types of surprise bills occurs after patients have been told by their plan and provider that the provider is in-network. If that information is wrong, the patient has no recourse. New York can fix that during this year’s legislative session.
Another problem is that states can only regulate some plans. Self-funded plans, which are usually plans people get through employment at very large companies, can only be regulated by the federal government. DFS recently required insurance companies to include what type of plan you have on every insurance card, which will help. The law also might not help you if your plan was issued outside of New York. New York has great regulators that do everything they can to protect consumers – but we need to make sure we have leaders in Washington that also care about patients and access to health care.
What should you do if you have a surprise bill? Ask for help! It can be hard for people to know if the law covers their bills or not. Community Health Advocates is a state program that connects you to counselors who can help figure it out – for free, and regardless of what insurance you have (if any). The counselors look at medical bills every day, so they can save you a lot of time – and maybe a lot of money! Their helpline number is 212-614-5400.