By: Karen E. Sosler, Esq.
Iseman, Cunningham, Riester & Hyde LLP
Albany/Poughkeepsie, New York
New York Health Care Providers Need to Comply with Law Addressing Out-of-Network Transparency and Coverage Reform.
The New York Emergency Medical Services and Surprise Bills Law became effective on April 1, 2015. The law mandates new disclosures to patients, expands the rules for health plans in relation to reimbursement for out-of-network services, and provides safeguards against surprise bills from out-of-network physicians and for emergency care. Physicians and physician groups must comply with the following:
Physicians and Physician Groups Are Required to Make the Following Disclosures to Current and Prospective Patients:
Prior to non-emergency services:
• Health care plans in which they participate; and
• Hospitals with which they are affiliated.
If physician or group does not participate in network of health plan:
• Prior to the provision of non-emergency services, that the amount or estimated amount to be billed is available upon request; and
• Upon receipt of a request, the amount or estimated amount to be billed absent unforeseen medical circumstances in writing.
Physicians Only Are Required to Make Additional Disclosures:
• To patients (including prospective), name, practice name, address, telephone number of any health care provider scheduled to perform anesthesiology, laboratory, pathology, radiology or assistant surgeon services in the physician's office; and
• To patients and hospitals if inpatient or outpatient hospital services are scheduled, the same information about other physicians scheduled to provide services and information about the health care plans they participate in.
New Requirements for “Surprise” Bills and Emergency Services
The new law also includes new billing and reimbursement requirements for certain non-emergency services provided by out-of-network providers if such billing is a “surprise” bill, including an independent dispute resolution process for such bills. In addition, there are new billing and reimbursement requirements for certain emergency services.
Various Technical Requirements Must Be Met
For each element of the new law, there are technical requirements that physicians and physician groups must comply with. For more information, contact the Health Care Practice Group at Iseman, Cunningham, Riester & Hyde at 518-462-3000.
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