What is a “surprise bill”?
A surprise bill is when a patient gets services from an out-of-network (OON) provider at an in-network hospital or other center and receives a bill for those services. A patient may get a surprise bill because:
- An in-network provider was not available
- An OON provider gave the patient services without his or her knowledge
- There was a medical problem or issue that came up at the time of the healthcare services
- The patient was referred by an in-network provider without his or her written consent and without being informed that the referral may result in costs not covered by his or her health plan
- An in-network provider sent a sample taken during a patient’s visit to an OON lab or specialist
- The patient’s primary doctor referred him or her to an OON provider
- The patient did not choose to get services from an OON provider instead of from an available in-network provider
If the patient chooses to receive services from an OON provider, charges for the services are not considered surprise bills.
What has New York State done to protect patients from surprise bills?
Imagine that you go to your gastroenterologist because you have been experiencing terrible abdominal pain. Your GI takes a CT scan, which is read by a radiologist and shows a mass on your appendix. A week later you have a laparoscopic appendectomy to remove your appendix, which is performed by a top notch surgeon in your plan’s network, and the mass is sent to a clinical laboratory to be biopsied in order to determine if it is cancerous. Three months later you receive an invoice for radiology, anesthesiology and clinical lab services from OON providers.
New legislation, passed in 2015 and known as the “Emergency Medical Services and Surprise Bills” law, is a much-heralded consumer protection law primarily intended to prevent this type of situation and guard against surprise bills for OON health care services.
Disclosure Obligations
The law imposes new disclosure obligations for health care professionals and plans:
Healthcare Providers: Healthcare providers like His Branches Health Services must:
Disclose to patients and prospective patients, in writing or through their website, their plan and hospital affiliations prior to the provision of non-emergency services and verbally at the time the appointment is scheduled.
An out of network provider must inform the patient, prior to providing non-emergency services, that (i) the actual or estimated amount for the service is available upon request, and (ii) if requested, will be disclosed in writing with a warning that costs could go up if unanticipated complications occur.
Physicians: In addition to the foregoing, a physician must provide a patient and the inpatient or outpatient hospital in which the patient is scheduled for admission with the name, practice name, mailing address and phone number of any other physician scheduled to treat the patient and information as to how to determine the health plans in which the provider participates.
Providers must provide patients with their network and hospital affiliations in writing or online. When patients make appointments, providers must indicate whether they participate in the patient’s network.
Prior to providing non-emergency services, providers must disclose to the patients their rights to know what will be billed for the procedure, and if the patient requests, they must disclose the anticipated cost, warning patients that costs could go up if unanticipated complications occur.
What we are doing to comply with the law
His Branches Health Services has always attempted to participate in every local health insurance plan that our patients may be enrolled in, and as many national plans as we can, to be able to provide comprehensive and continuous care to every patient who wishes to receive their medical care at our community health center. The major plans that we participate in as well as our primary hospital affiliations are listed on this page – just call us at (585) 235-2250 if you have any questions about your coverage for any of our services.
We ask every patient when they enroll for care, make an appointment, or arrive at their appointment to give us information about their current health insurance, not only so that we can submit their bill properly but so that we can inform them of any copay or other charges that their visit might require of them.
When we make referrals for laboratory tests, X-rays, or specialists, we always include the most accurate information we have about the patient and their insurance.
We are proud members of Accountable Health Partners, an organization associated with the University of Rochester Medical Center (UR Medicine) that describes itself as “a clinically integrated network of hospitals and physicians that exists to deliver quality healthcare and an outstanding patient experience and rewards its members for the value they bring to the healthcare system.” What this means is that we can back up into a broad and deep range of specialty and hospital services locally knowing that they will receive and help us care for our patients in a seamless way that provides excellent care while avoiding “surprise bills” at the same time.
