Surprise Bills for Health Care Services
MetroPlus reminds Participating Providers that routine referrals should only be made to Participating Providers. MetroPlus will only cover services provided by out-of-network providers for emergency services and when prior authorization is obtained and we have approved a specific out-of-network provider. Prior authorization to obtain services from an out-of-network provider will only be approved when MetroPlus determines that we do not have a Participating Provider with the appropriate training and experience to treat a member's condition. Prior authorization will not be approved for convenience. If you believe your patient needs to obtain services from an out-of-network provider, please contact MetroPlus before referring the patient to an out-of-network provider.
What You Need to Know About Surprise Bills If You Are A Health Care Provider
If your patient has coverage through an HMO or insurer subject to NY law (coverage that is not self-insured):
- Hospital and Ambulatory Surgical Center. A bill will be a surprise bill if your patient receives services from a non-participating doctor at a participating hospital or ambulatory surgical center and: (1) a participating doctor was not available; or (2) a non-participating doctor provided services without your patient's knowledge; or (3) unforeseen medical circumstances arose at the time the health care services were provided.
- Referral. A bill will also be a surprise bill if your patient is referred by a participating doctor to a non-participating provider and your patient did not sign a written consent acknowledging that the services would be out-of-network and would result in costs not covered by the patient's health plan. A referral occurs: (1) during the course of a visit with a participating doctor, a non-participating provider treats the patient; or (2) the patient's participating doctor takes a specimen from the patient in the office (for example, blood) and sends it to a non-participating laboratory or pathologist; or (3) for any other health care services when referrals are required under the patient's plan.
- Assignment of Benefits Form. When your patient signs an assignment of benefits form for a surprise bill, your patient will only be responsible to pay you the in-network cost-sharing. You are required to hold your patient harmless for any amounts in excess of your patient's in-network cost-sharing and your patient's health plan will pay you directly for the services. The health plan is required to pay you the billed amount or attempt to negotiate reimbursement with you. If attempts to negotiate do not result in a resolution of the payment dispute, the health plan will pay you an amount that it determines is reasonable. You may dispute the amount that the health plan pays you through the independent dispute resolution process.
- When You Bill A Patient. If you are a doctor and are billing a patient for what could be a surprise bill, you are required to include an assignment of benefits form and a claim form for a third party payer with the patient's bill.
If you do not believe that a bill meets the definition of a Surprise Bill, contact the Consumer Assistance Bureau of the Department of Financial Services and submit any relevant information.
Doctors. You may dispute the amount that the health plan pays you for emergency services through the independent dispute resolution process if you do not participate with a patient's health plan. However, the following emergency services are exempt from the IDR process: CPT codes 99281 - 99285, 99288, 99291 - 99292, 99217 - 99220, 99224 - 99226, and 99234 - 99236 if the bill does not exceed 120% of the usual and customary cost and the fee disputed is $613.50 (adjusted annually for inflation rates) or less after any applicable co-insurance, co-payment and deductible.
See additional DFS Physician Disclosure Requirements:
1. If a patient has an unscheduled hospital admission (for example, through the emergency department) and is stabilized but requires additional inpatient treatment, a physician that treats the patient during the hospital admission:
- Would not be required to provide the patient with written documentation identifying the health care plans in which the physician participates because the services are not being rendered at the physician’s office, practice or health center. See Public Health Law § 24(1).
- Would not be required to verbally tell the patient the health care plans in which the physician participates because the patient did not schedule an appointment. See Public Health Law § 24(1).
- Would not be required to tell the patient that the amount the physician will bill is available on request (if the physician does not participate with the patient’s health plan) because the services are not being rendered at the physician’s office, practice or health center. See Public Health Law § 24(2).
- Would not be required to provide the patient with the name, practice name, mailing address and telephone number of any health care provider scheduled to perform anesthesiology, laboratory, pathology, radiology or assistant surgeon services because the services are not being provided in connection with care in the physician’s office or coordinated or referred as part of the office visit. See Public Health Law § 24(3).
- Would not be subject to the disclosure requirements in § 24(4) of the Public Health Law for services provided during the admission because § 24(4) applies only to a scheduled hospital admission.
2. Public Health Law § 24(3) requires a physician to provide a patient or a prospective patient with the name, practice name, mailing address and telephone number of any health care provider scheduled to perform anesthesiology, laboratory, pathology, radiology or assistant surgeon services in connection with care to be provided in the physician’s office for the patient or coordinated or referred by the physician for the patient at the time of referral to or coordination of services with such provider.
- If the physician coordinates or makes a referral to a specific physician in a practice, the physician should disclose the name of the physician.
- If the physician only coordinates or makes a referral to the overall practice and it is up to the practice to schedule the physician, the physician need only disclose the name of the practice.
3. Public Health Law § 24(4) requires a physician, for a patient’s scheduled hospital admission or scheduled outpatient hospital services, to provide a patient and the hospital with the name, practice name, mailing address and telephone number of any other physician whose services will be arranged by the physician and are scheduled at the time of the pre-admission testing, registration or admission at the time non-emergency services are scheduled.
- If the physician arranges for a specific physician in a practice, the physician should disclose the name of the physician.
- If the physician only arranges for the overall practice and it is up to the practice to schedule the physician, the physician need only disclose the name of the practice.
For more information, go to the NY State Department of Financial Service website