New York State’s Department of Financial Services receives thousands of complaints every year about unexpected medical bills received by people who thought their expenses were covered by their insurance plans. In fact, it’s the No. 1 complaint the department receives on health-care issues, according to The New York Times.
Last year, state lawmakers passed legislation designed to allay such unforeseen expenses, which can often lead to consumer medical debt. On March 31 of this year, the Emergency Medical Services and Surprise Bills law went into effect. Chuck Bell, programs director for Consumers Union, which advocated for the reform, says that the state has created “one of the strongest laws in the country” on this issue.
“These comprehensive, carefully formulated provisions are a huge step forward for preventing unexpected medical bills, which put significant financial and psychological strain on New York patients and their families,” Bell told Clarion.
In the lead-up to the law’s passage, advocates shared with state lawmakers more than 100 stories from patients who are hit with unexpected bills. Such post-procedure sticker-shock often affects patients who are inadvertently treated by out-of-network providers when visiting an emergency room, hospital or physician’s office.
But there are many situations in which patients have little or no control over which doctors treat them.
“I had lung cancer surgery by an in-network surgeon in an in-network hospital. But I was billed by the anesthesiologist who was not in-network. I had no choice,” wrote Lester from New York City, who is identified only by his first name in the story he shared with Consumers Union. “[What] was I supposed to ask when introduced to him in the operating room, ‘Do you accept Atlantis…?’”
The situation Lester describes is not uncommon and is shared by thousands of New Yorkers who go for a procedure at an in-network provider, only to find out, after the fact, that a specialist like a radiologist, or pathologist or anesthesiologist is not part of the insurer’s network.
Under the new law, someone facing one of these unexpected out-of-network bills could be “held harmless,” or free from legal responsibility, according to an overview of the law prepared by the Consumers Union. For emergency services, patients cannot be held responsible for more than the usual in-network co-pays. When these charges come up, the law shifts responsibility to insurance companies and doctors. A state mediation board set up by the law will facilitate agreements between an insurer and doctors who do not participate in that insurer’s network.
Duke It Out
“[The patient] can basically say, ‘Look, doctor, I’m giving you this claim [to take] against the insurance company. You and the insurance company can duke out how much you get paid,’” Mark Scherzer, a health insurance attorney who advocated for the law’s passage, told Clarion. Scherzer wrote a blog post detailing the provisions in the new law. “It’s very helpful to get the consumer out of the equation.”
The law also requires insurance companies to meet new standards – “network adequacy rules” – for their provider networks. With those rules in place they could help someone like Melissa, who wrote to the Consumers Union about the absence of allergists or immunologists in her insurer’s network within 20 miles of her home.
“I’m not in the boondocks,” she wrote. “So do we wait for the allergic asthma to send my child to the ER [because there’s a] lack of a specialist?”
Under the new law, if a network is determined to be insufficient, the insurance companies will be responsible for giving in-network rates for out-of-network providers. Details of the law, such as the definition of an adequate network, will be determined by a work group appointed by the governor. Even with the new protections, affordable health care advocates advise those insured under HMO or PPO plans to ask whenever possible whether all providers seen in a medical visit will be in-network, and to be ready to challenge unfair medical billing. Formal complaints may be filed with the NY Department of Financial Services.