DFS Clarifies that Post-Stabilization Services for MMC-Insured Patients Eligible for Dispute Resolution
As previously reported, the New York State Department of Financial Services (DFS) recently issued a comprehensive guidance (https://www.dfs.ny.gov/apps_and_licensing/health_insurers/nyoon_law_guidance_questions_federal_ns_act) for the processing of surprise medical bills that includes a clarification that “post-stabilization” claims for patients insured by a Medicaid managed care plan are, in fact, eligible for IDR. In addition, the guidance provides that, beginning with dates of service on or after January 1, 2023, Essential Plan 3 & 4 coverage are eligible for emergency service IDR disputes.
Resubmission Permitted. Given the number of complaints received by MSSNY member physicians raising concerns that these “post-stabilization” claims were previously rejected from NYS IDR, this is an important positive development. Furthermore, MSSNY staff has received communication from the DFS noting that any IDR relating to Medicaid Managed Care coverage for post-stabilization services that were rejected on the basis that they were not eligible for IDR may be resubmitted.
Time Limit for Resubmission. DFS advises that otherwise applicable timely filing limits will be waived if the claim is now past the deadline but was timely when first submitted. DFS is asking all affected physicians to resubmit these disputes within 120 days, and also asks these re-submissions be staggered over that time period so as to not overwhelm the IDREs.
Post-Stabilization Only, Not Emergency. DFS staff have stressed the importance of physicians reviewing the claim prior to re-submission to verify that the dispute actually relates to post-stabilization or inpatient services before they resubmit the dispute. Emergency (pre-stabilization) services for patients insured by Medicaid managed care plans are not eligible for IDR. To that end, DFS has instructed the IDREs to screen these submissions to determine if the patient was in fact stable at the time the services were rendered. If the IDRE determines that the patient was not stable at the time the services were rendered, the dispute will be rejected and the provider will be subject to an administrative fee.
