Have you ever woken up from a medical procedure and been informed that you were treated by an out-of-network physician?
Have you ever been treated in a non-urban area and sought the treatment of an in-network specialist – only to find out that the only available treating physician was not in network?
Have you ever been provided medical services costing thousands of dollars by an out-of-network physician without even knowing it until the bill arrived?
- You wake up from surgery only to find out that the anesthesiologist they used was not in your network and is charging $40,000 for his/her services.
- You are charged for an out-of-network, consulting physician and you never even met them.
- You are forced out-of-network because you are in a location where there is no in-network equivalent physician for what you need.
As of April 1, 2015, thanks to the new Emergency Medical Services and Surprise Bills law, this practice is no longer acceptable in New York State. The law requires full transparency on all such decisions, otherwise any physician brought in must be paid the same rate as in-network physicians.
Patients now have the right to appeal to their insurance company when they are not made aware of out-of-network physicians being used, and they are entitled to only pay the in-network rates.
All health insurance plans are now required to provide all health needs under any circumstances without having to rely on more expensive out-of-network services, known as network inadequacies. If the health insurance plan brings in out-of-network providers, even for emergency services, it must use people who will accept network rates, or pay them without billing the patient extra.
For example, if there is no lung cancer surgeon in network, then the insurance company must choose one who is out-of-network and agree to pay their fee. The use of out-of-network physicians happens frequently in surgery, especially cosmetic surgery, and is something the law will stop.
This law has new, powerful rules for disclosure requiring that health insurance networks keep provider network listings up-to-date and physicians to list the insurance companies they accept and hospital affiliations in writing. Insurance companies must now update their provider network listings and hospital affiliations within 15 days after changes.
Providers must provide patients with a roster of the specialists they typically refer people to, as well as the diagnostic facilities they use, in writing or online. Furthermore, hospitals must warn patients that physician services may not be covered. It is the duty of the hospital to alert the patient if the physician is in-network or out-of-network at the hospital.
Physicians must disclose to patients what they will be billed for the procedure, and if it ends up being more, the patient is not required to pay it. Hospitals are required to give patients all the information they need, and if the hospital brings in an out-of-network consulting physician, the hospital needs to give patients the opportunity to say no to that.
This law is much more consumer-oriented than previous ones. The new law requires insurance companies, not patients, to coordinate and negotiate medical services and fees. If violations occur, patients have the right to appeal to the insurance company.