Decoding Your Doctor Bill: A Guide to Surprise Medical Billing and Your Rights

Navigating healthcare costs can be confusing, especially when you receive unexpected medical bills. It’s crucial to understand your rights and protections, particularly concerning surprise medical bills. In New York, strong regulations are in place to shield consumers from unexpected costs when receiving care from out-of-network providers in in-network facilities, or for emergency services. These protections extend to individuals with health insurance from insurers or HMOs operating under New York law.

This guide breaks down what you need to know about surprise medical billing, whether:

• You have health coverage through an insurer or HMO regulated by New York law.
• You are uninsured, or your employer or union provides self-insured coverage not subject to New York law.
• You are a healthcare provider seeking clarity on billing regulations.

Understanding Surprise Medical Bills and How to Protect Yourself

Surprise medical bills, often referred to as “Doctor Bills” in everyday conversation, occur when you receive unexpected charges from out-of-network providers. This commonly happens in two scenarios:

1. Out-of-Network Care at an In-Network Facility: You are treated by a doctor or specialist who is not part of your health plan’s network while you are at a hospital or ambulatory surgical center that is in your network.
2. Referred to an Out-of-Network Provider: Your in-network doctor refers you to a provider outside of your network for further services.

In these situations, New York law ensures you are only responsible for the in-network cost-sharing amounts (like copayments, coinsurance, and deductibles) you would typically pay if you saw an in-network provider.

Situations Defined as Surprise Billing at In-Network Facilities

It’s considered a surprise bill when an out-of-network provider treats you within an in-network hospital or ambulatory surgical center under these circumstances:

• No In-Network Provider Available: An in-network specialist in your required field was not available to provide the necessary treatment at the time.
• Unforeseen Out-of-Network Services: You unknowingly received services from an out-of-network provider while undergoing treatment at the in-network facility.
• Emergency or Unplanned Medical Needs: Unforeseen medical services from an out-of-network provider were required during your course of treatment.

Important Note: It is not a surprise bill if you consciously choose to receive care from an out-of-network provider when an in-network option was readily available before you arrived at the hospital or ambulatory surgical center.

Starting January 1, 2022, specific services are frequently categorized as surprise bills when provided by an out-of-network provider in a hospital or ambulatory surgical center. These include:

• Emergency medicine
• Anesthesia
• Pathology
• Radiology
• Laboratory services
• Neonatology
• Assistant surgeon services
• Hospitalist services
• Intensivist services

For healthcare services received before January 1, 2022, surprise bill protections were primarily focused on instances where an out-of-network physician (not necessarily other types of healthcare providers) treated you 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 if:

• Lack of Informed Consent: You did not sign a written consent form acknowledging that the referred services were out-of-network and would not be covered at in-network rates by your health plan.
• Unintentional Out-of-Network Treatment: During a visit with your in-network doctor, you are unexpectedly treated by a non-participating provider within the same facility.
• Out-of-Network Lab Work: Your in-network doctor takes a specimen (e.g., blood sample) in their office and sends it to an out-of-network laboratory or pathologist for analysis without your explicit consent or knowledge of network status.
• Required Referrals Under Your Plan: Any other healthcare services for which your health plan requires a referral, and the referral leads to an out-of-network provider without proper notification and consent.

Action Steps if You Receive a Surprise Bill

If you believe you have received a surprise bill because an out-of-network provider treated you at an in-network hospital or ambulatory surgical center, or due to an out-of-network referral from your doctor:

• Pay Only In-Network Cost-Sharing: You are legally obligated to pay only the in-network cost-sharing amounts stipulated by your health plan.
• Balance Billing is Prohibited: If the out-of-network provider bills you for any amount exceeding your in-network cost-sharing (copayment, coinsurance, or deductible), this is termed “balance-billing,” and it is prohibited under New York law in surprise billing scenarios.
• Submit a Surprise Bill Certification Form: If your doctor referred you to an out-of-network provider, it is essential to send a Surprise Bill Certification Form to both your health plan and the provider. This form formally notifies them that you have received a surprise bill and are entitled to protection from balance billing.
• Certification Form for Pre-2022 Services: If you received healthcare services before January 1, 2022, at an in-network hospital or ambulatory surgical facility from an out-of-network provider, you must also submit the Surprise Bill Certification Form to your health plan and provider to activate surprise bill protections. While not mandatory for services post-January 1, 2022, at in-network facilities, it is still highly recommended for clarity and documentation.
• File a Complaint: You have the option to file a formal complaint with the New York State Department of Financial Services (DFS) if you encounter issues with surprise billing.

Protections for Self-Funded Employer/Union Coverage

If your health insurance is through an employer or union that self-funds its coverage (indicated on your health insurance ID card as “self-funded” or lacking “fully insured” designation), the Federal No Surprises Act provides similar protections against surprise medical bills.

These federal protections apply to plans issued or renewed on or after January 1, 2022, and cover surprise bills from out-of-network providers in in-network hospitals or ambulatory surgical centers. You are only responsible for your standard in-network cost-sharing in these situations.

For detailed information on federal consumer protections, please visit the CMS No Surprises Act website.

For plans issued or renewed before January 1, 2022, and for disputes not covered under the federal act, you may be eligible for an independent dispute resolution (IDR) process through New York State. This process allows you to challenge the bill if services were provided by a doctor at a hospital or ambulatory surgical center, and you were not given all legally required information about your care. Refer to the sections “Information Your Doctor and Other Health Care Professionals Must Give You” and “Information Your Hospital Must Give You” for details on mandatory disclosures.

To initiate a dispute, complete an IDR Patient Application and mail it to: NYS Department of Financial Services, Consumer Assistance Unit/IDR Process, One Commerce Plaza, Albany, NY 12257.

Navigating Healthcare Costs When Uninsured

For individuals without health insurance, or those who choose not to use their insurance (“self-pay patients”), there are mechanisms to promote cost transparency and dispute resolution.

Good Faith Estimates for the Uninsured

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 is a crucial tool for understanding potential doctor bill costs upfront.

Providers must furnish this estimate within specific timeframes:

• Scheduled Services (3+ Business Days Ahead): Within 1 business day of scheduling.
• Scheduled Services (10+ Business Days Ahead): Within 3 business days of scheduling.
• Estimate Upon Request: Within 3 business days of your request for an estimate.

The good faith estimate must include:

• A clear description of the primary service you will receive.
• A list of any other services reasonably expected to be provided in conjunction with the primary service.
• Relevant diagnosis and expected service codes (medical billing codes).
• The provider’s estimated charges for all listed services.

For more comprehensive information on good faith estimates, visit the CMS No Surprises Act website.

Patient-Provider Dispute Resolution for Good Faith Estimates

If the final bill you receive is at least $400 more than the good faith estimate provided by your healthcare provider, you have the right to initiate a federal patient-provider dispute resolution process. You must request this review within 120 days of receiving the bill.

An independent reviewer will assess the good faith estimate, the actual bill, and supporting information from the provider to determine a reasonable payment amount, if any, for each service in question.

Initially launched in 2022, this federal dispute resolution process applies to billing disputes with the provider who scheduled your primary service. Future expansions will allow disputes with other providers involved in related services as well.

Further details on the patient-provider dispute resolution process are available on the CMS No Surprises Act website.

New York State Dispute Resolution Without a Good Faith Estimate

If your 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 include services provided by a doctor at a hospital or ambulatory surgical center, and the absence of legally required information disclosure about your care. Again, refer to “Information Your Doctor and Other Health Care Professionals Must Give You” and “Information Your Hospital Must Give You” for a list of required disclosures.

To initiate this process, submit an IDR Patient Application to: NYS Department of Financial Services, Consumer Assistance Unit/IDR Process, One Commerce Plaza, Albany, NY 12257.

Mandatory Information Disclosure: What Your Doctor and Healthcare Professionals Must Tell You

To empower patients and prevent surprise doctor bills, New York law mandates that doctors and other healthcare professionals, including group practices, diagnostic and treatment centers, and health centers, must provide patients and prospective patients with specific information:

• Health Plan Network Participation: You must be informed, in writing (or via website) before non-emergency services and verbally when scheduling an appointment, about the names of health plans in which the provider is in-network.
• Hospital Affiliations: Similarly, you must receive written (or website) and verbal disclosure about the hospitals with which your provider is affiliated or where they could admit you.
• Service Cost Estimates: If your provider is out-of-network with your health plan, they are obligated to provide you with an estimated amount they will bill you for services, upon your request.
• Information on Referred Providers: If your doctor schedules or refers you for specific services performed in their office or elsewhere (anesthesiology, laboratory, pathology, radiology, or assistant surgeon services), they must disclose:
  • The referred provider’s name (if a specific provider within a practice is scheduled).
  • The name of the provider’s practice.
  • The provider’s address.
  • The provider’s telephone number.
• Information for Hospital Services: When your doctor schedules hospital services and arranges for other doctors to treat you within the hospital, they must provide:
  • The name of each doctor.
  • Each doctor’s practice name.
  • Each doctor’s address.
  • Each doctor’s telephone number.
  • Instructions on how to verify if each doctor is in-network with your health plan.

Hospital Disclosure Requirements

Hospitals also have mandatory disclosure obligations to help patients avoid surprise doctor bills and understand costs:

Hospitals must prominently post on their websites:

• Charge Information: A list of their standard charges for services, or clear instructions on how to obtain this information if a direct list is not posted.
• In-Network Health Plans: A comprehensive list of the health plans with which the hospital is in-network.
• Doctor Charges Within the Hospital: Clear information stating:
  • Services provided by doctors within the hospital are billed separately and are not included in the hospital’s charges.
  • Doctors providing services at the hospital may or may not be in the same health plan networks as the hospital itself.
  • Patients should proactively ask the doctor arranging their hospital services about the network status of all involved physicians.
• Contracted Doctor Groups: The names, addresses, and phone numbers of doctor groups contracted by the hospital to provide specific services (e.g., anesthesiology, pathology, radiology), along with instructions on how to contact these groups to verify their network status.
• Hospital-Employed Doctors: The names, addresses, and phone numbers of doctors directly employed by the hospital who treat patients, and the health plans in which these employed doctors participate.

Hospitals must provide in registration or admission materials (before non-emergency services):

• Doctor Network Status Inquiry Recommendation: Instructions to contact the doctor arranging hospital services to confirm:
  • The names, practice names, addresses, and phone numbers of any other doctors that the primary doctor will arrange to treat you in the hospital.
  • Whether doctors employed or contracted by the hospital (for services like anesthesiology, pathology, and radiology) are expected to be involved in your care.
• Instructions for Verifying Doctor Network Status: Guidance on how to determine if doctors employed by the hospital (for ancillary services) are in-network with your specific health plan.

Emergency Services and Surprise Billing Protections

New York law and the federal No Surprises Act provide robust protections against surprise medical bills for emergency services.

Emergency Services with NY Law-Regulated Health Insurance

If you have health insurance regulated by New York law (“fully insured” plans), you are only required to pay your in-network cost-sharing amounts (copayment, coinsurance, and deductible) for out-of-network emergency services received at a hospital.

• This protection covers bills from doctors, the hospital itself*, and, starting in January 2022, any other providers involved in your emergency care.
• It extends to inpatient services if you are admitted to the hospital directly from the emergency room.
• Providers can only bill you for your standard in-network cost-sharing for emergency services, including any subsequent inpatient care related to the emergency.
• If you receive a bill from an out-of-network provider for emergency services that exceeds your in-network cost-sharing, immediately notify your health plan.
• You also have the option to file a complaint with the DFS.

Emergency Services and Self-Funded Employer/Union Coverage

For individuals with self-funded employer or union health plans, the Federal No Surprises Act protections apply to out-of-network emergency service bills for plans issued or renewed on or after January 1, 2022. This includes inpatient care following emergency room treatment (“post-stabilization services”).

Your financial responsibility is limited to your in-network cost-sharing for emergency services.

For detailed information on federal consumer protections, visit the CMS No Surprises Act website.

For plans issued before January 1, 2022, you may be eligible for New York State’s independent dispute resolution (IDR) process to challenge emergency service bills. Note that you may be required 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. To apply, complete an IDR Patient Application and send it to the NYS Department of Financial Services.

Emergency Services for the Uninsured

If you are uninsured and receive a bill for emergency services in New York that you believe is excessive, you can utilize the New York State independent dispute resolution (IDR) process. Similar to insured individuals with older self-funded plans, you may need to pay an IDR fee (up to $395) if your dispute is not successful, unless you meet the income hardship threshold (below 250% of the Federal Poverty Level).

To initiate a dispute, submit an IDR Patient Application to the NYS Department of Financial Services.

Healthcare Provider Guidance on Surprise Billing Regulations

These regulations also provide clear guidelines for healthcare providers to ensure compliance and fair billing practices.

Surprise Bills with NY Law-Regulated Insurance (Non-Self-Funded)

As a healthcare provider, it is crucial to understand that you are limited to billing your patient only for their in-network cost-sharing amount in cases of:

• Surprise Bills in Hospitals or Ambulatory Surgical Centers
• Surprise Bills Resulting from Out-of-Network Referrals

Health plans are mandated to directly pay out-of-network providers for surprise bills, removing the patient from the payment dispute process beyond their in-network responsibility.

Defining Surprise Bills in Hospitals/Ambulatory Surgical Centers for Providers:

A bill for services in these facilities qualifies as a surprise bill if:

• Your patient receives services from an out-of-network provider* at an in-network facility, and one of the following conditions is met:

  1. An in-network provider was not available to render the necessary service.
  2. Services were provided by an out-of-network provider without the patient’s prior knowledge or consent.
  3. Unforeseen medical circumstances arose during the healthcare service delivery, necessitating out-of-network care.

• It is NOT a surprise bill when an in-network provider was available, and the patient knowingly and willingly chose to receive services from an out-of-network provider. In such cases, providers must have adhered to all notice requirements under the No Surprises Act and Public Health Law regarding scheduled services.

  • Patients must be given a meaningful opportunity to choose an in-network provider in advance of services (ideally at least 72 hours prior). Notice provided on the day of service is generally insufficient for meaningful choice.
  • If a patient signs the standard written notice and consent form acknowledging out-of-network status and potential costs, it may not be considered a surprise bill for certain services (though surprise bill protections often still apply to emergency medicine, anesthesiology, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services, even with written notice and consent).
  • If out-of-network service was pre-authorized by the health plan in advance, and the patient received proper notice of out-of-network status and required disclosures (including estimated plan payment), it is typically not a surprise bill.

  (*For services provided before January 1, 2022, surprise bill protections primarily applied to services from out-of-network physicians only, not all healthcare providers, within in-network facilities.)

Defining Surprise Bills from Out-of-Network Referrals for Providers:

A bill for services resulting from an in-network doctor’s referral to an out-of-network provider is a surprise bill if:

• Your patient did not sign a written consent form acknowledging the out-of-network status and potential for non-covered costs, and one of these scenarios occurred:
  1. During a visit with an in-network doctor, an out-of-network provider unexpectedly treated the patient.
  2. The patient’s in-network doctor collected a specimen (e.g., blood) and sent it to an out-of-network laboratory or pathologist without informed consent.
  3. For any other healthcare services requiring referrals under the patient’s plan, where an out-of-network referral occurred without proper notification and consent.

Surprise Bill Certification Form for Providers:

Out-of-network providers have the option to ask patients to sign a Surprise Bill Certification Form at the time of service. If used, a copy must be sent to the patient’s health plan. For services at in-network hospitals or ambulatory surgical centers on or after January 1, 2022, out-of-network providers can use this form to notify the health plan of surprise billing situations when submitting claims.

Mandatory Disclosure of Balance Billing Protections for Providers:

Providers are legally required to make publicly available, post on their websites, and provide to patients a one-page notice detailing:

• Federal requirements and prohibitions against balance billing for emergency services and surprise bills.
• New York State requirements prohibiting balance billing in similar scenarios.
• Information on how patients can contact New York and federal agencies if they believe balance billing prohibitions have been violated.

The Department of Financial Services offers a model disclosure form that providers can use to meet these disclosure obligations.

Dispute Resolution for Insurers and Providers

For disputes between providers and insurers concerning surprise bills or emergency service bills for insured patients, both parties must utilize the DFS portal to obtain a case number for initiating the dispute resolution process.

DFS Portal Access: DFS Portal

First-time users will need to create a portal account and then request access to NY IDR via the “Ask for Apps” tab. Upon submitting the IDR request, a case number will be assigned.

Once you have a case number:

• Complete the IDR Provider and Insurer Application.
• Send the application to the designated Independent Dispute Resolution Entity (IDRE).

Surprise Bills for Uninsured Patients – Provider Information

If your patient is uninsured, a bill is considered a surprise bill under New York law if: services are provided by a doctor at a hospital or ambulatory surgical center, and the patient did not receive all legally mandated information about their care (refer to “Information Your Doctor and Other Health Care Professionals Must Give You” and “Information Your Hospital Must Give You“). In such cases, the uninsured patient can dispute the bill amount through the New York State independent dispute resolution process.

Surprise Bills for Patients with Self-Funded Coverage – Provider Information

The Federal No Surprises Act extends surprise bill protections to patients with self-funded employer or union coverage for plans issued or renewed on or after January 1, 2022, when receiving care from out-of-network providers at in-network hospitals or ambulatory surgical centers. In these situations, patients are only responsible for their in-network cost-sharing.

For comprehensive details on the federal IDR process for surprise bills, providers can consult the CMS No Surprises Act website.

For plans issued or renewed before January 1, 2022, patients with self-funded coverage may qualify for New York State’s IDR process if they receive a surprise bill (defined as services from a doctor in a hospital or ambulatory surgical center without full mandatory information disclosure – see relevant sections above).

Emergency Service Bills – Provider Information for NY Law-Regulated Insurance (Non-Self-Funded)

Billing Restrictions for Emergency Services:

If you are an out-of-network provider rendering emergency services in a hospital (including inpatient care following emergency room treatment), you are legally prohibited from billing the patient for any amount exceeding their in-network cost-sharing (copayment, coinsurance, or deductible).

Payment for Emergency Services:

Health plans are required to directly reimburse out-of-network providers for emergency services, simplifying the payment process.

Independent Dispute Resolution (IDR) for Providers:

Out-of-network healthcare providers (including hospitals) can utilize the New York State independent dispute resolution process to dispute the payment amount they receive from a health plan for emergency services in a hospital, including payment for subsequent inpatient care.

Dispute Resolution for Insurers and Providers (Emergency Services)

The process for dispute resolution related to emergency service bills is the same as for surprise bills. Providers and insurers must use the DFS portal to obtain a case number and initiate the IDR process as described earlier.

DFS Portal: DFS Portal

Emergency Service Bills – Provider Information for Self-Funded Coverage

The Federal No Surprises Act protections also apply to emergency service bills for patients with self-funded employer or union coverage for plans issued on or after January 1, 2022. Patients are limited to their in-network cost-sharing responsibilities for emergency services.

For detailed information on the federal IDR process for emergency services, providers should consult the CMS No Surprises Act website.

For plans issued or renewed before January 1, 2022, patients may be eligible for New York State’s IDR process to dispute emergency service bills.

Emergency Service Bills – Provider Information for Uninsured Patients

Uninsured patients have the right to dispute emergency service bills through the New York State independent dispute resolution process.

Submitting a Dispute Through New York IDR – Provider Guide

To initiate a dispute through the New York Independent Dispute Resolution (IDR) process for surprise bills or emergency service bills involving insured patients, providers and insurers must use the DFS portal to obtain a case number:

DFS Portal: DFS Portal

Independent Dispute Resolution Entity (IDRE) Review Process

IDRE Review and Expertise:

Disputes are reviewed by certified Independent Dispute Resolution Entities (IDREs). Decisions are made by reviewers with specialized training and experience in healthcare billing and reimbursement, in consultation with a licensed physician actively practicing in the same or similar specialty as the physician who provided the service under dispute.

30-Day Decision Timeframe:

The IDRE is mandated to make a determination within 30 days of receiving the complete dispute application. All parties must submit all required information with their initial application and promptly upon any IDRE request. Failure to provide timely information may result in it not being considered in the review.

IDRE Fee Determination:

• For disputes involving health plans, the IDRE will choose either the out-of-network provider’s billed charge or the health plan’s initial payment offer as the appropriate amount.
• For disputes submitted by uninsured patients, the IDRE independently determines a reasonable and appropriate fee.

Factors Considered by IDREs:

When making a determination, IDREs must consider various factors, including:

• Disparity in Fees: Whether there is a significant difference between the provider’s charged fee and:
  1. Fees paid to the same provider for similar services to out-of-network patients covered by other health plans.
  2. Fees typically paid by the health plan to similarly qualified out-of-network providers for the same services in the same geographic region.
• Provider Qualifications: The provider’s training, education, experience, and their usual charges for comparable services when not participating in the patient’s health plan network.
• Hospital Characteristics: In cases involving hospitals, the teaching status, scope of services offered, and patient case mix complexity of the hospital.
• Case Complexity: The specific circumstances and medical complexity of the patient’s case.
• Patient Factors: Relevant patient characteristics that may influence service costs.
• Physician Service Costs: For physician services, the usual and customary cost of the specific service in the relevant market.

Negotiation for Settlement:

In situations where settlement appears likely, or if the gap between the health plan’s payment and the provider’s fee is deemed unreasonably large, the IDRE may direct the involved parties to engage in good faith negotiations to reach a mutually acceptable settlement.

Binding Review:

The IDRE’s determination is legally binding on all parties involved, but it is also admissible as evidence in court proceedings if further legal action is pursued.

Payment Responsibility for Independent Dispute Resolution (IDR)

IDR Costs – Disputes Between Providers and Health Plans (Insured Patients):

• Provider Pays: The provider is responsible for the cost of the dispute resolution process if the IDRE determines that the health plan’s initial payment was reasonable.
• Health Plan Pays: The health plan bears the IDR costs if the IDRE finds the provider’s billed fee to be reasonable.
• Shared Costs (Settlement): If a settlement is reached through IDRE-directed negotiation, the provider and health plan typically share the dispute resolution costs on a prorated basis.
• Minimal Fees (Ineligible/Incomplete Disputes): A minimal fee may be charged to the provider or health plan submitting the dispute if the IDRE deems the dispute ineligible for review or if the application was incomplete.

IDR Costs – Disputes Involving Uninsured Patients:

• Provider Pays: The provider is responsible for the IDR costs if the IDRE determines that the provider’s fee was not reasonable.
• Patient Pays (Conditional): The patient pays the IDR costs if the IDRE deems the provider’s fee reasonable, unless this payment would constitute a financial hardship for the patient. “Hardship” is defined as a household income below 250% of the Federal Poverty Level.

Questions and Assistance with IDR

For any questions regarding the Independent Dispute Resolution (IDR) process or for assistance with completing an application, please contact (800) 342-3736 or email [email protected]. When inquiring, please specify the date(s) of service, as different regulations and processes may apply depending on when services were received.

Becoming a Certified IDRE

For those interested in becoming a certified Independent Dispute Resolution Entity (“IDRE”), further information is available on our IDRE information page or via email at [email protected].