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NY protections against surprise out-of-network medical bills to take effect this week

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ALBANY, New York — New protections against big surprise medical bills are starting in New York.

Enacted last year, they require insurance payments for out-of-network medical treatment in emergencies, when similar services or specialists are unavailable within the insurer's network or when care is provided without the patient's knowledge.

"The surprise bill is only in a situation where they couldn't choose in advance," said Dr. Andrew Kleinman, a surgeon and president of the Medical Society of the State of New York. "If they're coming to see me in my office, that's not a surprise."

The immediate requirement for doctors and hospitals is to update online or give written notice to patients about the insurance networks they belong to and tell patients about treatment referrals to other doctors, lab testing or other services. Their trade associations have been providing briefings and guidance.

The Department of Financial Services, which regulates insurers, has received more than 10,000 consumer complaints about billing for out-of-network health care, Superintendent Ben Lawsky said. His agency was involved in drafting the law, which the Cuomo administration pushed.

"This is a huge national problem," Lawsky said. One other state, Illinois, has taken a similar approach to drop consumers out of billing disputes between insurers and care providers, and officials in many other states have taken an interest in New York's approach, he said.

Chuck Bell, program director for Consumers Union, said it should remove consumers from the disputes that could drag on for months and now can go to independent dispute resolution.

The law also provides patients a basis for defending treatment when no similar provider is available within their insurer's network, Bell said. "That incentive will encourage health plans to have stronger networks and make it possible for consumers to stay within their networks," he said.

Mandated coverage begins Tuesday with newly issued or renewal policies. It doesn't cover cases where consumers simply choose an outside physician or treatment instead of available network providers.

The majority of doctors are in insurance networks, Kleinman said. "The problems were with the interactions out-of-network where patients just didn't understand what was going on," he said.

Health maintenance organizations, or HMOs, already must authorize out-of-network coverage for emergency services, with patients required to pay only their usual network deductibles, copayments and coinsurance.

That requirement will now extend to other insurers as well. They will pay what they deem reasonable to doctors, who can take disagreements to independent dispute resolution. There's a form for out-of-network providers to have patients fill out so they can get insurance payments. The Medical Society, which represents about 20,000 of New York's more than 60,000 licensed doctors, has a link on its website to the new state form.

For hospitals, the primary adjustment is coping with disclosures they need to post about insurance plans they participate in and to ensure patients get information about what physicians and facilities they contract with, according to the Healthcare Association of New York State.

With surprise bills, the most obvious scenario in hospitals with an admitted patient is where an out-of-network specialist consults under somewhat urgent circumstances, said Jeffrey Gold, association senior vice president for managed care. It's somewhat similar to emergencies, he said.

"There's not a lot of disclosure there, either," Gold said. "It's really just a matter of making sure an out-of-network doctor and plan adequately insulate the consumer from any liability,"

Leslie Moran, spokeswoman for the New York Health Plan Association, emphasized that many new provisions will apply to insurance policies bought or renewed, that for many consumers they will be effective next Jan. 1. Insurers' contracts and policies have to be rewritten, which is taking place. They're trying to make sure everyone has the same rules and understands them, she said.

Another provision provides for greater transparency on costs, including those for out-of-network services so consumers can see them. "We hope it provides them with a better understanding of the true cost of health care," she said.


Online:

Department of Financial Services consumer guidance:

http://www.dfs.ny.gov/consumer/hrights.htm

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