Beginning March 31, there will be a brand new process for out of network physicians to be paid by an insurance company who provide “emergency” patient care or where such physicians’ involvement in a patient’s treatment in a hospital or ambulatory surgical center is considered to be a “surprise” to the patient.  Such “surprise bill” circumstances include where: a participating doctor was not available; a non-participating doctor provided services without the patient’s knowledge; or unforeseen medical circumstances arose at the time the health care services were provided.  

The final regulations adopted by the New York State Department of Financial Services to implement this new process are here   To read a summary of the process, click here:

For a bill for emergency care, the out of network physician will continue to submit the bill for the services to the patient’s insurance company.   The new law enacted last year requires the insurance company to pay what it deems reasonable for the services rendered, and then it will be up to the physician or insurer to bring the dispute for the remaining balance to an independent dispute resolution (IDR) entity. 

For a so-called surprise medical bill, the out of network physician will need to send a claim form to the patient along with a special assignment of benefits form (available here ) In this case, the physician will submit his or her bill to the insurance company along with the patient Assignment of Benefits form .  As with ER bills, the insurance company will pay the physician what it deems reasonable for the services rendered, and it will up to the physician or the carrier to bring any dispute regarding the remaining balance to the IDR entity.

The form for physicians to send to request a resolution of their dispute is available here:

The application form calls upon the physician applying to the IDR entity to include within its application: a) a representative sample of at least 3 fees received by the provider in the past 24 months for the same service, in the same region, from health plans in which the provider does not participate; b) The provider’s level of training, education and experience in relation to the service; and c) the provider’s usual charge for similar services when the provider does not participate with the health plan.  The IDR entity is required to consider these factors, along with the usual and customary charge for the service (available from the Fair Health website), the individual patient characteristics, and the circumstances and complexity of the case. 

The IDR entity is required to consider whether there is a gross disparity between the fee charged by the physician and (1) fees paid to the physician for the same services provided to other patients in health care plans in which the provider is non-participating, and (2) the fees paid by the health plan to reimburse similarly qualified out-of-network providers for the same services in the same region;

Clearly, it is very important for the physician bringing the dispute to provide as much specific information as possible to justify the fee the out of network physician believes he or she is due.  

The statute requires that review by the IDR entity include a review by a physician in the same or specialty as the physician who claim is being reviewed.

Specifically, the IDR entity will have 3 days following the application of a physician or insurer to screen for eligibility and conflicts of interest.  Within 3 days following a determination that the claim is eligible for resolution, the IDR entity must request additional information from the physician and health plan which are subject to the dispute.  The physician and health plan will then have 5 days to provide the information requested by the IDR entity, consistent with what is required in the Statute.   

These time frames are quite “tight” because the statute requires the IDR entity to complete review of the dispute within 30 days of receipt of the application. 

To encourage “reasonableness” on both sides, the IDR entity is required to choose between the plan payment and physician’s bill, similar to the arbitration process used by Major League Baseball.  In rare cases when a settlement could be likely or the positions represent “unreasonable extremes”, the IDR entity may direct the parties to within 10 days negotiate a compromise, concurrent with the 30-day time overall time limit for a decision.

A physician bill for emergency services or that is a surprise bill is exempt from the IDR process when physician fees are subject to schedules or other monetary limitations under any other law, such as Workers Compensation, No-fault, Medicare, and Medicaid fee-for-service.  According to the DFS, Medicaid managed care is exempt from IDR if the bill is for emergency services and is not exempt from IDR if the bill is a surprise bill.

Claims for certain CPT codes (99281 through 99285, 99288, 99291 through 99292, 99217 through 99220, 99224 through 99226, and 99234 through 99236) under $613 are exempted from the IDR altogether.

The “winner” of the IDR process is responsible for making the payment.   If good faith negotiations directed by the IDRE results in a settlement between the insurer and physician, the insurer and physician   shall evenly divide and share the prorated cost for dispute resolution.

This is but one of many important new provisions contained within this new law that takes effect March 31.  For more information, here is a link a comprehensive MSSNY summary of the new law.