Consumers often face unexpected medical bills, especially in situations involving out-of-network providers or emergency services. In New York, strong consumer protections are in place to shield residents from these financial shocks. This guide acts as your “Bill Doctor,” providing you with the knowledge and tools to understand and navigate surprise medical bills, ensuring you pay only what you rightfully owe.
Whether you have health insurance through an HMO or insurer subject to New York law, are uninsured, or have self-insured coverage not subject to these laws, understanding your rights is crucial. This article breaks down these protections and empowers you to take control of your medical billing.
Understanding Your Rights: Key Protections Against Surprise Bills
Surprise medical bills typically arise in two main scenarios:
- Out-of-network provider at an in-network facility: You receive care from a provider who is not within your health plan’s network while at a hospital or ambulatory surgical center that is in your network.
- Referral to an out-of-network provider: Your in-network doctor refers you to a specialist or service outside of your health plan’s network.
In New York, if you have health insurance coverage governed by state law (often indicated by “fully insured” on your insurance card), you are protected from balance billing in these surprise bill situations. Balance billing is when an out-of-network provider bills you for the difference between their charge and the amount your insurance pays. With surprise bill protections, you are only responsible for your in-network cost-sharing (copayments, coinsurance, and deductibles).
Surprise Bills at In-Network Hospitals or Ambulatory Surgical Centers
A medical bill is considered a surprise bill when you are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center under the following circumstances:
- No in-network provider was available: The necessary specialist or provider within your network was not available at the time of your treatment.
- Services without your knowledge: You were unknowingly treated by an out-of-network provider while receiving care at an in-network facility.
- Unforeseen medical services: Unexpected medical needs arose during your treatment, requiring services from an out-of-network provider.
It’s important to note that if you choose to receive services from an out-of-network provider at an in-network facility when an in-network option was available, it is generally not considered a surprise bill.
Alt text: Concerned patient in hospital bed, highlighting the worry associated with potential surprise medical bills.
Services Typically Considered Surprise Bills (Starting January 1, 2022):
For services received on or after January 1, 2022, the following are commonly classified as surprise bills when delivered by an out-of-network provider at an in-network hospital or ambulatory surgical center:
- Emergency medicine
- Anesthesia
- Pathology
- Radiology
- Laboratory services
- Neonatology
- Assistant surgeon services
- Hospitalist services
- Intensivist services
Important Note for Services Before January 1, 2022:
If your healthcare services were provided before January 1, 2022, surprise bill protections were more limited. Protection only applied to treatment by an out-of-network physician (not other types of healthcare providers) at an in-network hospital or ambulatory surgical center.
Surprise Bills from Out-of-Network Referrals
You are also protected from surprise bills when your in-network doctor refers you to an out-of-network provider under specific conditions:
- No Informed Consent: You did not sign a written consent form acknowledging that the referred services were out-of-network and would not be fully covered by your health plan.
- In-office Treatment by Out-of-Network Provider: During a visit with your in-network doctor, you are unexpectedly treated by an out-of-network provider within the same office.
- Out-of-Network Lab Work: Your in-network doctor takes a specimen (like blood) in the office and sends it to an out-of-network laboratory or pathologist for analysis.
- Referral Requirements: Any other healthcare services that require a referral under your specific health plan.
What to Do If You Receive a Surprise Bill
If you believe you have received a surprise medical bill because you were treated by an out-of-network provider at an in-network facility or due to an out-of-network referral, here’s how to take action and act as your own “bill doctor”:
- Pay Only In-Network Cost-Sharing: You are legally obligated to pay only your in-network cost-sharing amounts for surprise bills.
- Balance Billing is Prohibited: If an out-of-network provider bills you for any amount exceeding your in-network cost-sharing (this excess amount is balance billing), you are protected.
- Submit a Surprise Bill Certification Form:
- For Out-of-Network Referrals: If you received a surprise bill due to a referral, you MUST send a Surprise Bill Certification Form to both your health plan and the out-of-network provider. This form formally notifies them that you received a surprise bill and are entitled to protection from balance billing.
- For Services Before Jan 1, 2022 at In-Network Facilities: If your services at an in-network hospital or ambulatory surgical center were before January 1, 2022, submitting the Certification Form is mandatory to activate surprise bill protections.
- For Services After Jan 1, 2022 at In-Network Facilities: While not strictly required for services after January 1, 2022, submitting the form is highly recommended to ensure your protections are recognized and processed smoothly.
- File a Complaint: You have the right to file a formal complaint with the New York Department of Financial Services (DFS) if you encounter issues with surprise billing. You can file a complaint here.
By taking these steps, you actively manage your medical bills and ensure you are not overcharged, effectively becoming your own “bill doctor.”
Protections for Self-Funded Employer/Union Coverage
If your health insurance is self-funded by your employer or union (your insurance card might say “self-funded” or not state “fully insured”), federal protections under the No Surprises Act apply for plans issued or renewed on or after January 1, 2022.
These federal protections mirror New York’s state protections for surprise bills received at in-network hospitals or ambulatory surgical centers from out-of-network providers. You are only responsible for your in-network cost-sharing in these situations.
For detailed information on federal consumer protections, visit the CMS No Surprises Act website.
Plans Issued Before January 1, 2022 (Self-Funded):
For self-funded plans issued or renewed before January 1, 2022, you may be eligible for New York State’s Independent Dispute Resolution (IDR) process to challenge a surprise bill. Eligibility requires that the services were provided by a doctor at a hospital or ambulatory surgical center, and you did not receive all legally required information about your care (see sections below on required information disclosure).
To initiate the IDR process, complete an IDR Patient Application and send it to the NYS Department of Financial Services at the address provided on the form.
Navigating Bills When Uninsured: Your “Bill Doctor” Strategy
If you are uninsured or choose not to use your health insurance for certain services, you still have rights and strategies to manage your medical bills effectively.
Good Faith Estimates for Uninsured Patients
Healthcare providers are legally obligated to provide uninsured or self-pay patients with a “good faith estimate” of expected charges before providing healthcare services. This estimate helps you understand potential costs upfront.
Timelines for Receiving Good Faith Estimates:
- Scheduled services (at least 3 business days ahead): Estimate within 1 business day of scheduling.
- Scheduled services (at least 10 business days ahead): Estimate within 3 business days of scheduling.
- Estimate request: Within 3 business days of your request.
Information Included in a Good Faith Estimate:
- Service description
- List of reasonably expected co-services
- Diagnosis and expected service codes (CPT/HCPCS codes)
- Expected charges for all listed services
For more in-depth information on good faith estimates, consult the CMS No Surprises Act website.
Alt text: Doctor explaining medical bill details to a worried patient, emphasizing patient-provider communication.
Patient-Provider Dispute Resolution for Good Faith Estimates
If your final medical bill is at least $400 higher than the good faith estimate you received, you have the right to dispute the charges through the Federal patient-provider dispute resolution process. You must initiate this dispute within 120 days of receiving the bill.
An independent reviewer will assess the good faith estimate, the final bill, and information from the provider to determine a reasonable payment amount.
This federal dispute resolution process became available in 2022, initially for disputes with the provider who scheduled your service. It will eventually expand to cover disputes with other providers involved in related services.
Further details on the patient-provider dispute resolution process can be found on the CMS No Surprises Act website.
New York State IDR for Lack of Good Faith Estimate
If a provider fails to provide a good faith estimate, and you believe the charges are unreasonable, you may qualify for New York State’s Independent Dispute Resolution (IDR) process. Eligibility criteria are similar to those for self-funded plans before 2022: services must be from a doctor at a hospital or ambulatory surgical center, and you must not have received all legally required information about your care.
To apply for the NYS IDR, complete the IDR Patient Application and submit it to the NYS Department of Financial Services.
Information Disclosure: What Your “Bill Doctor” Needs to Know
Both healthcare professionals and hospitals in New York are required to provide patients with specific information to promote transparency and help prevent surprise bills. Being aware of these requirements empowers you to be a more informed healthcare consumer.
Information Your Doctor and Healthcare Professionals Must Provide
Doctors and other healthcare professionals, including group practices, diagnostic centers, and health centers, must provide the following information to patients and prospective patients:
- Health Plan Networks: Written or website disclosure of the health plans in which the provider is in-network, provided before non-emergency services. Verbal confirmation of network participation is required when scheduling appointments.
- Hospital Affiliations: Written or website disclosure of affiliated hospitals or hospitals where the provider has admitting privileges, provided before non-emergency services. Verbal confirmation when scheduling appointments.
- Cost of Services (Out-of-Network): If the provider is out-of-network with your health plan, they must provide an estimated cost of services upon request.
- Providers Scheduled by Your Doctor (In-Office or Referrals): If your doctor schedules or refers you for anesthesiology, laboratory, pathology, radiology, or assistant surgeon services, they must disclose:
- Provider’s name (if a specific provider is scheduled within a practice)
- Provider’s practice name
- Provider’s address
- Provider’s phone number
- Providers Scheduled by Your Doctor (Hospital Services): If your doctor schedules other doctors to treat you in a hospital, they must disclose:
- Doctor’s name
- Doctor’s practice name
- Doctor’s address
- Doctor’s phone number
- Instructions on how to verify if the doctor is in-network with your health plan.
Information Your Hospital Must Provide
Hospitals in New York have website posting and pre-service material disclosure requirements:
Website Disclosure:
- Charges: A list of hospital charges or information on how to obtain this list.
- Health Plan Networks: List of health plans in which the hospital is in-network.
- Doctor Charges Disclosure: Statement clarifying that doctor services within the hospital are billed separately and may or may not be in the same networks as the hospital. Patients should inquire with the arranging doctor about network status.
- Contracted Doctor Groups: Name, address, and phone number of doctor groups contracted by the hospital for services like anesthesiology, pathology, and radiology, along with instructions to contact these groups to verify network participation.
- Hospital-Employed Doctors: Name, address, and phone number of doctors employed by the hospital, and the health plans in which they are in-network.
Pre-Service Material Disclosure (Registration/Admission):
- Contact Your Doctor: Hospitals must advise patients to check with the doctor arranging hospital services to determine:
- Details (name, practice, contact info) of any other doctors scheduled to treat you in the hospital.
- Whether hospital-employed or contracted doctors (e.g., anesthesiologists, pathologists, radiologists) are expected to be involved in your care.
- In-Network Verification: Instructions on how to determine if hospital-employed doctors are in-network with your health plan.
Emergency Services: Your “Bill Doctor” in an Emergency
When you require emergency services, surprise bill protections are particularly critical.
Emergency Services for Insured Patients (NY Law Coverage)
If you have health insurance subject to New York law, your cost-sharing responsibilities for out-of-network emergency services at a hospital are capped at the in-network level. This applies to:
- Bills from doctors
- Hospital bills*
- Bills from any other providers treating you during the emergency (starting January 2022)
- Inpatient services if you are admitted to the hospital after emergency room treatment.
Providers can only bill you for your in-network cost-sharing for emergency services, including any subsequent inpatient care.
Action Steps:
- Inform Your Health Plan: Notify your health plan if you receive a bill from an out-of-network provider for emergency services.
- File a Complaint: You can also file a complaint with the DFS here.
Emergency Services for Self-Funded Coverage
Federal No Surprises Act protections extend to emergency services for individuals with self-funded employer or union health plans issued or renewed on or after January 1, 2022. This includes post-stabilization services after emergency room treatment.
You are only responsible for in-network cost-sharing for emergency care in these plans. Refer to the CMS No Surprises Act website for further details.
Plans Issued Before January 1, 2022 (Self-Funded):
For self-funded plans issued before 2022, you may be eligible for New York State’s Independent Dispute Resolution (IDR) process to dispute emergency service bills. Note that you may have to pay a fee for IDR (up to $395) if the provider’s bill is upheld, unless your household income is below 250% of the Federal Poverty Level.
Apply for IDR using the IDR Patient Application.
Emergency Services for Uninsured Individuals
Uninsured individuals in New York can also utilize the state’s Independent Dispute Resolution (IDR) process to challenge emergency service bills they believe are excessive. Similar to self-funded plans pre-2022, there may be an IDR fee (up to $395 if the bill is upheld, potentially waived for low-income individuals).
Use the IDR Patient Application to initiate a dispute.
“Bill Doctor” Resources for Healthcare Providers
This section provides essential information for healthcare providers to ensure compliance with surprise billing regulations.
Surprise Bills for Insured Patients (NY Law Coverage)
Providers are restricted to billing patients only for their in-network cost-sharing for surprise bills in hospitals/ambulatory surgical centers or surprise bills resulting from referrals. Health plans are required to pay out-of-network providers directly for surprise bills.
Defining a Surprise Bill (Hospital/Ambulatory Surgical Center):
A bill is a surprise bill if:
- A patient receives services from an out-of-network provider* at an in-network facility under these conditions:
- No in-network provider was available.
- Services were provided by an out-of-network provider without the patient’s knowledge.
- Unforeseen medical circumstances arose during treatment.
When it’s NOT a Surprise Bill:
- If an in-network provider was available, and the patient chose to use an out-of-network provider.
- Providers must provide all required notices under the No Surprises Act and Public Health Law regarding scheduled services.
- Patients must have a meaningful opportunity to choose an in-network provider at least 72 hours before services (notice on the day of service is insufficient).
- It’s not a surprise bill if the patient signs a standard written notice and consent form (though surprise bill protections often still apply to emergency medicine, anesthesiology, etc., even with consent).
- Pre-authorized out-of-network services with proper patient notice and disclosures are also not surprise bills.
(*For services before January 1, 2022, surprise bill protection for hospital/ambulatory surgical center services only applied to out-of-network physicians, not other provider types.)
Defining a Surprise Bill (Out-of-Network Referral):
A bill is a surprise bill if:
- The patient did not sign written consent acknowledging out-of-network status and potential uncovered costs, AND:
- An out-of-network provider treats the patient during an in-network doctor visit.
- An in-network doctor sends a specimen to an out-of-network lab/pathologist.
- Other services requiring referrals under the patient’s plan.
Surprise Bill Certification Form for Providers:
Out-of-network providers can use a Surprise Bill Certification Form. For services at in-network facilities on or after January 1, 2022, providers can sign and submit this form with the claim to the health plan.
Balance Billing Disclosure Requirements for Providers:
Providers must publicly disclose (posting in locations, websites, and providing to patients) a one-page notice in clear language detailing:
- Federal and New York prohibitions on balance billing for emergency and surprise bills.
- Information on contacting New York and federal agencies regarding potential violations.
The DFS offers a model disclosure form to meet these requirements.
Dispute Resolution for Insurers and Providers
Insurers and providers disputing surprise bills or emergency service bills for insured patients must use the DFS portal to obtain a case number.
DFS Portal Access:
- Create a Portal account (if first-time user).
- Use “Ask for Apps” tab to request access to NY IDR.
- Submit IDR application to receive a case number.
DFS Portal Link: https://myportal.dfs.ny.gov/
Application Submission:
Once you have a case number:
- Complete the IDR Provider and Insurer Application.
- Send the application to the assigned Independent Dispute Resolution Entity (IDRE).
Surprise Bills for Uninsured Patients (Provider Information)
For uninsured patients, a bill is a surprise bill if services are from a doctor at a hospital or ambulatory surgical center, and the patient did not receive all required information about their care (see sections on information disclosure). In these cases, patients can dispute the bill through the New York State IDR process.
Surprise Bills for Self-Funded Coverage (Provider Information)
Federal No Surprises Act protections apply to self-funded plans issued or renewed on or after January 1, 2022. Patients are only responsible for in-network cost-sharing for surprise bills in these plans.
For plans issued before 2022, patients with self-funded coverage may use the New York State IDR process if they did not receive all required information about their care from a doctor at a hospital or ambulatory surgical center.
Emergency Service Bills for Insured Patients (NY Law Coverage – Providers)
Billing Restrictions: Out-of-network providers for emergency services at hospitals (including inpatient care after ER) are prohibited from billing patients beyond their in-network cost-sharing.
Payment Requirements: Health plans must pay out-of-network providers directly for emergency services.
Provider IDR Rights: Out-of-network providers (including hospitals) can dispute payment amounts for emergency services through the New York State IDR process.
Emergency Service Bills for Self-Funded Coverage (Providers)
Federal No Surprises Act protections for emergency service bills apply to self-funded plans issued or renewed on or after January 1, 2022. Patient responsibility is limited to in-network cost-sharing.
For plans issued before 2022, patients may use New York State IDR to dispute emergency service bills.
Emergency Service Bills for Uninsured Patients (Providers)
Uninsured patients can dispute emergency service bills through the New York State IDR process.
New York Independent Dispute Resolution (IDR) Process for Providers
Providers or insurers initiating disputes must use the DFS portal to obtain a case number (see instructions above).
Independent Dispute Resolution Entity (IDRE) Review Process
IDRE Reviewers: Disputes are reviewed by independent entities (IDREs) with trained reviewers experienced in healthcare billing and reimbursement. They consult with licensed physicians in the relevant specialty.
30-Day Decision Timeframe: IDREs make determinations within 30 days of receiving the dispute. Parties must submit all required information with their application and promptly upon IDRE request; late information may be disregarded.
IDRE Determination:
- Insured Patient Disputes: IDRE chooses either the out-of-network provider’s bill or the health plan’s payment amount.
- Uninsured Patient Disputes: IDRE determines a reasonable fee.
Factors Considered by IDRE:
- Disparity between provider’s charge and:
- Provider’s fees for similar out-of-network services to other patients.
- Health plan’s reimbursements to similarly qualified out-of-network providers in the same region.
- Provider’s training, experience, and usual charges for non-plan-participating services.
- Hospital’s teaching status, service scope, and case mix (if applicable).
- Case complexity and circumstances.
- Patient characteristics.
- Usual and customary cost of the service (for physician services).
Negotiation Direction: IDREs may encourage good faith negotiation if settlement seems likely or payment/fee discrepancies are significant.
Binding Review: IDRE decisions are binding but admissible in court.
IDR Payment Responsibilities
Insured Patient Disputes (Provider vs. Health Plan):
- Provider Pays: If IDRE finds the health plan’s payment reasonable.
- Health Plan Pays: If IDRE finds the provider’s fee reasonable.
- Shared Cost: Prorated cost sharing in case of settlement.
- Minimal Fee: May apply to the submitting party if the dispute is ineligible or incomplete.
Uninsured Patient Disputes:
- Provider Pays: If IDRE finds the provider’s fee unreasonable.
- Patient Pays: If IDRE finds the provider’s fee reasonable, unless it poses a hardship (household income below 250% of Federal Poverty Level).
IDR Questions and Contact Information
For IDR process questions or application assistance, call (800) 342-3736 or email [email protected]. Include service date(s) in inquiries as different rules may apply based on service dates.
Becoming a Certified IDRE
For information on becoming a certified Independent Dispute Resolution Entity (IDRE), visit IDRE information page or email [email protected].
