What you need to know about surprise bills if you’re a health care provider
New York State has established a new process to resolve disputes on surprise bills. Health plans, doctors who treat members of health plans in which they don’t participate, facilities, and patients have the right to request an independent review from New York State if they do not believe a bill or its payment was reasonable.
Under New York State law, bills for services provided by a non-participating provider for emergencies, and surprise bills, are eligible for dispute resolution.
What is a surprise bill?
If your patient has coverage through a fully insured commercial, Article 47 ASO, Medicaid, or Child Health Plus:
- Hospital and ambulatory surgical center. A bill will be a surprise bill if your patient receives services from a non-participating doctor at a participating hospital or ambulatory surgical center and: (1) a participating doctor was not available; or (2) a non-participating doctor provided services without your patient's knowledge; or (3) unforeseen medical circumstances arose at the time the health care services were provided.
- Referral. A bill will also be a surprise bill if your patient is referred by a participating doctor to a non-participating provider and your patient did not sign a written consent acknowledging that the services would be out-of-network and would result in costs not covered by the patient's health plan. A referral occurs when: (1) during the course of a visit with a participating doctor, a non-participating provider treats the patient; or (2) the patient's participating doctor takes a specimen from the patient in the office (for example, blood) and sends it to a non-participating laboratory or pathologist; or (3) a referral is required under your plan for any other health care services.
- When you bill a patient. If you’re a doctor and are billing a patient for what could be a surprise bill, you are required to include an assignment of benefits form and a claim form for a Third Party Payer with the patient's bill.
- Assignment of Benefits form. When your patient signs an Assignment of Benefits form for a surprise bill, your patient will only be responsible to pay you their in-network cost-share. You are not allowed to ask your patient to pay more. Your patient’s health plan is responsible for paying the rest or negotiating a different reimbursement amount with you.
If attempts to negotiate the payment dispute do not result in a resolution, the health plan will pay you an amount that it determines is reasonable. You may dispute the amount that the health plan pays you to New York State’s Independent Dispute Resolution Entity (IDRE).
To file an appeal:
1. Go to dfs.ny.gov
2. Receive a file number.
3. Download the IDRE dispute application at: dfs.ny.gov/consumer/health/IDR_Provider_Application.pdf
4. Send it to the assigned IDRE.
If you need any assistance, please call 1-800-342-3736 or e-mail IDRquestions@dfs.ny.gov.