NYS Surprise Bill Act

Scope:

This policy will apply to all patients regardless of payer or service. This policy applies throughout OH, including the hospital and all of its departments and health centers, OH affiliated physician practices (Oneida Medical Services, PLLC and Oneida Medical Practice, PC), the Extended Care Facility and any other department or entity which is part of OH.

Oneida Health will ensure that we abide by the requirements set forth in the New York State Emergency Medical Services and Surprise Bills law.  The statue requires disclosures to the patients regarding out-of-pocket expenses to be made by the health plans, providers and hospitals.

Disclosures may differ dependent on whether it is a Emergency Service or Non-emergency service.  The disclosures also may differ between what Oneida Health Hospital must disclose and what their affiliated physician offices may have to disclose as a provider/group practice.  This policy will serve to assist in distinguishing the required disclosures.

Hospital Website Disclosures:

Oneida Health Hospital will provide disclosure on our external website, www.oneidahealth.org, as follows: To the extent required by Federal guidelines, access to the hospital’s standard charges for items and services it provides, including Diagnosis Related Groups (DRGs); A list of participating health plans; A statement that states the following:

1. Physician services provided in the hospital are not included in the hospital charges;
2. Physicians who provide services in the hospital may or may not participate with the same health plans as the hospital;
3. Encourage the prospective patient to check with the physician arranging for the hospital services to determine the plans with which the physician participates; and
4. As applicable, the name, address, and telephone number of the physician groups that the hospital has contracted with to provide services, including anesthesiology, pathology, or radiology, along with instructions on how to contact those groups to determine the health plans in which the physicians participate.

Registration / Patient Intake Disclosures:

Oneida Health will provide disclosure to our patients in advance of non-emergent hospital service,  in all of our patient intake/registration areas including, but not limited to, our offsite departments, units and health centers as follows. In addition, we will include this information in any mailing that is provided to a scheduled patient prior to their service.

Advise the patient or prospective patient to check with the physician arranging the hospital services to determine the name, practice name, address, and telephone number of any other physician whose services will be arranged by the physician, and whether the services of physicians who are employed or contracted by the hospital to provide services, including anesthesiology, pathology, and/or radiology, are reasonably anticipated to be provided to the patient; and

Provide patients or prospective patients with information about how to determine, in a timely manner, the health plans in which the physicians participate

OH’s Physician Affiliates Disclosures:

At Oneida Health, we have 5 affiliated physician specialty offices that include Ortho, Neuro, Women’s Health, ENT services and Quick Care.  These offices fall under the scope of this policy as indicated above and will provide disclosures to their patients and prospective patients as follows:

The name, practice name, address, and telephone number for any provider scheduled to perform anesthesiology, laboratory, pathology, radiology, or assistant surgeon services in connection with care to be provided in the physician’s office or referred or coordinated by the physician at the time of referral or coordination; and

For a scheduled admission or outpatient service, provide the patient and the hospital with the name, practice name, 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 prior to the provision of services; and information about how to determine the plans in which the physician participates.

Health Care Professional Disclosures:

If the Health care professional participates in one or more health plans, they must provide patients and prospective patients the following disclosures:

The plans in which they participate either in writing or on their Web site; and A list of hospitals the health care professional is affiliated with prior to providing non-emergency services, and verbally at the time an appointment is scheduled.

If the Health care professional does not participate with a health plan, they must:

Inform the patient or prospective patient, before the nonemergency services are provided, that the amount the healthcare professional will bill is available upon request; and Upon receipt of this patient request, disclose in writing the amount or estimated amount (or fee schedule for health centers) that will be billed for services provided or anticipated to be provided absent unforeseen medical circumstances that may arise when services are provided.

This disclosure of information will be accomplished at a variety of different times and methods. The information could be presented at the time of scheduling an appointment (offices, health centers, etc), at the time the patient is registered, provided by the Ancillary Department where the service is provided (if the patient bypasses Patient Access) and/or sent by mail in anticipation of a scheduled visit.  This will be accomplished   by providing each patient with a letter “Important Information about Paying for Your Care at Oneida Health ” (etc, refer to links below).  We will also provide each patient with a listing of all of the applicable contracted providers associated with our facility and their billing service contact information (refer to links below).

Again, all of this information will be posted and available on our website at www.oneidahealth.org.

Uninsured/Self-Pay Patient

All uninsured and self-pay patients have the right to request and receive a good faith estimate on any scheduled service, in accordance with the No Surprise Act. In addition to the requirement of notification to the existence of a Patient-Provider Dispute Resolution process and their right to dispute a bill if within the parameters set forth in the regulation.

• Right to Receive a Good Faith Estimate of Expected Charges
• Good Faith Estimate for Health Care Items and Services

Other Notable Mandates in the Law:

With respect to Emergency Services, patients are only responsible for in-network price and will not be liable to pay more than their usual price sharing or co-payments, regardless of whether the providers were in-network or out-of-network.

With respect to Other services, when a patient receives treatment from an out-of-network provider where there were no in-network providers available, or where the provider failed to provide the disclosures required under the law, the patient is only responsible for their in-network price, and may assign their claims to the out-of-network provider, who must seek any additional reimbursement directly from the patient’s health insurer.  There is an independent review process set up to deal with reimbursement disputes between healthcare providers and health plans.  (Please Note:  This process excludes bills for emergency services resulting in bills less than $600 with this amount subject to change).

Dispute Resolution:

In the event of a dispute between Providers and health plans over the fee charged for medical services, there is an independent review process to deal with the dispute.  However, there is an exclusion for bills for emergency services resulting in charges less than $600.  Patients have the right to bring disputes for payment of bills for emergency services and surprise bills to independent dispute resolution under New York Financial Services Law (FSL) Article 6, §606.

Hospital bills are NOT subject to Dispute Resolution. This only applies to providers and patients.

State and Health Plans themselves can pursue dispute resolution.  Oneida Healthcare does not have to notify patients about the dispute resolution process.

References:

New York State Surprise Bill Section 24 of PHL;  Part H of Chapter 60
New York State Surprise Bill:  Proposed 23 NYCRR 200 “Independent Dispute Resolution for Emergency Medical Services and Surprise Bills Law”
New York State Out-of-Network (OON) Consumer Protection Law (2014-2015 New York State Budget)
Affordable Care Act – 42 U.S.C. §300gg-18(e); 79 Federal Register 50145-50146
Financial Services Law (FSL) Article 6, FSL §606

Forms:

OHC Important Information About Paying for Your Care (01519).pdf
OHC Patient Notification of Contracted Providers-Services OHC (00251) (2).pdf
WHA Patient Notification of Contracted Providers-Services (01516).pdf
WHA Important Information About Paying for Your Care (01518).pdf
OMP Patient Notification of Contracted Providers-Services Oneida Ortho Neurology(01517).pdf
Ortho Important Information About Paying for Your Care Oneida Ortho (01520).pdf
Neuro Important Information About Paying for Your Care Neurology Specialist (01521).pdf
Quick Care Important Information About Paying for Your Care (01523).pdf
Quick Care Patient Notification of Contracted Providers-Services (01522).pdf
ENT Specialists Patient Notification of Contracted Providers-Services (01525).pdf
ENT Important Information About Paying for Your Care (01526).pdf
ED NY Team Health Payer Notice (01527).pdf

Approved by: Revenue Cycle Management Team, 3/31/15