What You Need to Know
- The federal No Surprises Act affects balance billing related to emergency care, and care by out-of-network providers at in-network hospitals.
- The new New York state proposal would affect insurers who use outdated provider network directories.
- The proposal would also affect consumers who get incorrect provider network status information when they call insurers.
The New York State Department of Financial Services wants health insurers to pay any extra bills when their out-of-date provider directories send patients to out-of-network doctors and hospitals.
The state has proposed regulations that would require health plans in the state to make up the difference when a patient sees an out-of-network provider because of the use of:
- a stale online directory
- stale information from a customer service call center
- a paper directory that included provider network status information that was wrong on the day the paper directory was published
For health insurance professionals in New York, the proposed regulation could create opportunities to help some clients who are facing unexpected medical bills.
Surprise Billing Basics
In the past, insurers typically referred to “surprise billing” as “balance billing,” or an effort by a health care provider to ask the patient to pay the balance of charges not covered by insurance.
Health insurers have argued that they need to be able to make out-of-network charges and other cost-sharing arrangements stick to encourage enrollees to shop for care carefully and to defend themselves and enrollees against providers’ pricing power.
What Your Peers Are Reading
Doctors and hospitals have argued that they provide critical services and that, when they are caring for out-of-network patients, they should not have to accept what they see as the unrealistically low prices plans often pay for in-network care.