How to Appeal a Surprise Medical Bill in New York
'02.04.2024'
Lyudmila Balabay
Health insurance in the US is very unpredictable. For example, you went to your doctor, got your blood tested, and then bam - surprise: a bill for $400, although the doctor was in your insurance network and was the one who sent you to this laboratory for a blood draw. Such “gifts” from hospitals are called surprise bills and they are illegal. The Federal No Surprises Act protects patients from them. But this is all on paper. In fact, the bills are surprises – a headache for millions of Americans. And many, not knowing that they are protected by law and can successfully appeal an unexpected medical bill, pay for it.
New Yorkers are protected by law from surprise bills in the following cases:
- If the patient received health care from a doctor or laboratory who is not in their network but is employed by a hospital that is in their network.
- If an in-network physician referred the patient to another specialist or laboratory outside the patient's insurance network.
- If the patient received emergency care, including inpatient care, after going to the emergency department.
IMPORTANT: If you make an appointment with an out-of-network doctor or laboratory, the bill for that service is not considered a surprise bill and you are responsible for paying it.
What you should do if you receive a surprise bill depends on the type of health insurance you have.
On the subject: Personal experience: my father ended up in the hospital without insurance. How we got MedicAid and closed accounts for $200
1. The health insurance card says fully insured
If your health insurance card says fully insured, you are not required to pay surprise medical bills from an out-of-network doctor at an in-network hospital. But this protection only works if your situation meets ONE of the following points:
- You went to see a doctor in your network, but he was unavailable, and the hospital sent you to an out-of-network doctor;
- An out-of-network provider provided services without your knowledge (for example, your doctor himself sent your tests to an out-of-network laboratory);
- During an appointment, an out-of-network doctor provided you with medical services that you did not plan to receive.
As of January 1, 2022, New York City patients are protected from surprise bills for out-of-network doctors who work at in-network hospitals. The following services are covered by the law:
- urgent Care;
- anesthesiology;
- pathology;
- radiology;
- lab tests;
- neonatology;
- assisting a surgeon;
- resuscitation.
You are also protected from surprise bills if a doctor in your network refers you to an out-of-network provider and you do not sign a written consent stating that you are aware of the out-of-network services and they are not covered by your health plan.
What to do if you receive a surprise invoice for one of the services listed above
- You should not
- pay the entire bill, your responsibility is to pay your share of the cost of services within the network (in-network cost-sharing).
- If an out-of-network provider bills you for more than your share of the in-network costs (copay, coinsurance or deductible), this is called balance-billing and you are not required to pay such bills.
- If your doctor referred you to an out-of-network doctor, you MUST send surprise invoice confirmation form your insurance company, as well as your doctor, and make sure they know you've received a surprise bill and you should be protected from paying for anything beyond your in-network responsibilities. In addition, you should submit this form if an out-of-network provider treated you at an in-network hospital and you received a surprise bill from them.
- In addition, you can file a complaint with the Department of Financial Services (DFS) State of New York.
2. The health insurance card does NOT say fully insured
Such cards may indicate self-funded or nothing at all, but what is important to us is that there is no “fully insured” mark. Typically, such cards are held by those who are insured by their employer or trade union.
Surprise bill protection applies to such insurance plans if they were issued or renewed after January 1, 2022. In this case, you are only required to pay your part of the cost of services within the network (in-network cost-sharing).
If your plan was signed up or renewed before January 1, 2022, you are not covered by the Federal No Surprises Act. But you can challenge a surprise bill through New York State's Independent Dispute Resolution (IDR). Here is a sample complaint to IDR. Complete this form and send to: NYS Department of Financial Services, Consumer Assistance Unit/IDR Process, One Commerce Plaza, Albany, NY 12257.
3. If you don't have health insurance
Of course, in this case, the bill for medical services cannot be called unexpected. But still, the patient has the right to know how much he will pay. Health care providers must give you a good faith estimate of expected costs before you come for your appointment. Here's how it works:
- if you made an appointment with a doctor/hospital/laboratory at least 3 working days before the appointment date, then within 1 working day from the date of the appointment the hospital must provide you with a good faith estimate;
- If you made an appointment at least 10 business days before your appointment date, an estimate of expected costs should be sent to you within 3 business days of your appointment.
What does a good faith estimate look like:
- a description of the service you will receive;
- a list of other services that are expected to be needed in conjunction with the service you receive;
- expected cost of services.
If you end up being billed for an amount that exceeds the good faith estimate by $400 or more, you may be able to dispute the bill under Federal patient-provider dispute resolution process. You can dispute a medical bill within 120 days of receiving it. An independent reviewer will review the good faith estimate, bill, and information from the hospital to determine the fair amount you should pay for each service.
