A year ago, New York enacted a law targeting surprise billing from out-of-network claims. In that short time, the law has widely been hailed as a reasonable compromise that mitigates the problem of balance billing, which had triggered thousands of complaints from patients to the state Department of Financial Services.
In that year, preliminary data show that insurers prevailed in disputes more often than providers in several hundred conflicts adjudicated by the state's independent entity.
Few conflicts between insurers and providers caused as much for patients as balance billing. Hospital chief executives often were caught in the crossfire, left to "explain why half the board seemed to have a relative who'd received an enormous balance bill for covered services," said Jeff Gold, HANYS senior vice president and special counsel, during an industry webinar last week to commemorate the law's anniversary.
The compromises reached by plans, doctors and hospitals seem to reflect a fairer process that better protects consumers.
"Almost all our colleagues in sister states are continuing to pull their hair out over this area of the law," said Gold.
The law requires new disclosures from insurers, hospitals and doctors to help patients avoid higher out-of-network bills. Hospitals must disclose which health plans they accept and list standard charges for services. Perhaps most important, they must alert patients that physicians working at an in-network facility may not actually participate in the insurance network and can therefore bill patients directly.
The state Department of Health is conducting a statewide audit to check compliance at 50 to 60 hospitals each quarter. It plans to survey all facilities by the end of the year, Gold said.
One closely watched provision of the law is the mechanism DFS created for providers and insurers to arrive at a reimbursement figure. DFS is using several contractors, including Island Peer Review Organization in Lake Success, Long Island, to review payment conflicts.
The process is settled through baseball-style arbitration, in which each party submits what they think is an appropriate payment amount. The independent contractor chooses between those two options.
The results so far have been fairly even.
Of 291 disputes over bills for emergency services, the amount paid by health plans was deemed reasonable in 22% of those cases. Providers won 13%, according to preliminary data shared by Gold during the webinar.
Data on situations in which the patient received a surprise bill for non-emergency care—in some cases after doing everything to stay in network, only to be treated by an out-of-network assistant surgeon or anesthesiologist—were less robust. Many claims were ineligible for the process or are still pending.
The data also were broken down by specialty. Plastic surgeons were involved in the largest number of disputes related to emergency services (21%). They were followed by doctors in emergency medicine (19%), orthopedic surgeons (8%) and general surgeons (6%).
Insurers were more likely to win disputes in cases where the final resolution awarded doctors $500 or less. With an increase in the amount under dispute, the playing field seemed to level, according to the preliminary data.
In emergency care treatment for which payments submitted to the independent contractor fell between $1,000 and $5,000, providers' charges were more reasonable in 18 cases; insurers' payment won out 20 times.
Despite the law's early promise, some billing clashes have been difficult to resolve for providers. One area is a provision in the law that requires written consent for an in-network physician to send a specimen to an out-of-network lab.
"That will probably take a while to get right," Gold said.