What is a surprise bill

If you receive health care or emergency services from an in-network doctor or hospital, you may unknowingly receive care from an out-of-network provider during that time and incur unanticipated expenses—called a surprise bill. Usually, the out-of-network provider sends a bill to your insurance company, which pays a portion of the bill. The remainder of the bill is then sent to you. To ensure a provider is in-network, check directly with your health insurance carrier.

Both federal and New York State laws protect patients from surprise bills, meaning bills for health care services, that are performed by an out-of-network provider without the patient’s prior knowledge or approval. This law requires physicians, ambulatory practices and hospitals to notify you about the health plans in which they participate and share the names and contact information for all providers who will be involved in your care, including those who are out-of-network. Providers must disclose health plan participation prior to rendering non-emergent services.  Patients are also entitled to a good faith estimate. The law also protects patients who receive emergency services from an out-of-network provider.

Hold harmless protections for insured patients

Your health insurance plan must protect you from bills for OON emergency services in a hospital—this is called a hold harmless protection. You do not have to pay out-of-network provider charges for emergency services (typically for services in a hospital emergency room) that are more than your in-network copayment, coinsurance or deductible. Let your insurance company know if you receive a bill from an out-of-network provider for emergency services.

Uninsured patients or patients with employer or union self-insured coverage

You may be able to file a dispute through the independent dispute resolution process if you do not have HMO or insurance coverage that is subject to New York state law (e.g., if you are uninsured or your employer or union self-insures) and you receive a bill from a doctor for emergency services that you believe is excessive.