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Health care costs

N.Y. law protects against surprise medical bills

David Robinson
The (Westchester County, N.Y.) Journal News
Medical stethoscope on a white background.

WHITE PLAINS, N.Y. — Dana Roberts was raising two children in Yonkers and suddenly found herself wasting hours on the phone fighting insurers and medical offices over a $1,500 bill.

She had to track down her medical records, talk to a lawyer and research similar cases. At one point, Roberts said she started recording conversations about settling the unexpected charge.

Her distrust seemed appropriate. Roberts, 33, said she was unconscious when the $1,500 was tacked onto her surgery cost.

"Nobody said the anesthesiologist was outside of my insurance network," she said.

Thousands of similar complaints by New Yorkers — many involving bills from specialists used unbeknownst to patients — prompted a state law seeking to protect against surprise medical charges. State regulators reported receiving at least 10,000 complaints about the problem.

The law, which took effect March 31, requires insurers and health care providers to give patients more information on out-of-network insurance charges that typically increase bills at least 20 percent.

Those higher charges apply when a patient is treated by a doctor or other provider outside their insurance plan's network. Under the new law, patients will only pay higher out-of-network bills if they choose to pursue the treatment after receiving sufficient warning.

Insurance plans are also being required to meet new standards for improving provider networks, as determined by an independent review board. When a network falls short, insurance companies and health care providers negotiate a deal and cover the out-of-network charge.

The law is considered a victory among patient advocate groups, but some of its protections don't address concerns about insurance plans sold on the Affordable Care Act exchange, called the New York State of Health.

A push to require plans sold on the government-run insurance marketplace to include out-of-network coverage failed last year. Many insurance companies and other business groups opposed the effort, saying it would have increased the up-front cost for coverage.

More than 2 million New Yorkers enrolled for 2015 in Affordable Care Act plans, many of which offer increasingly narrow provider networks that limit choice, and thus expose patients to out-of-network charges.

"New York State of Health should offer affordable out-of-network coverage options, which are particularly important for patients with complex health care needs," Chuck Bell, program director of Consumers Union, said.

Debate over amending regulations and laws affecting plans sold on New York State of Health will ramp up again in the summer and fall, when the enrollment process begins anew for 2016.

For Roberts, the current surprise medical bill law came too late. Her kidney stone surgery was in 2012, about three months after her son's birth. The collection agent called months later in 2013, seeking payment of the $1,500 anesthesiologist bill.

The debt collection shocked Roberts, who thought the bill had been settled in 2012 between her insurer, EmblemHealth, the Westchester Anesthesiologist group, in Rye Brook, and Lawrence Hospital Center, in Bronxville. She said she ended up paying $500 after reaching an agreement that reduced the bill.

EmblemHealth officials said they couldn't discuss a specific case. They said EmblemHealth supports the surprise medical bill law, saying it works to protect members from unexpected health care costs. The nonprofit insures about 3.4 million people, and a spokesman said there are programs seeking to better educate members about health care cost.

For example, the company has an online cost calculator that estimates out-of-pocket payments for common medical procedures, the spokesman said.

Officials at New York-Presbyterian Healthcare System, which took over Lawrence Hospital Center in a 2014 merger, said they couldn't comment on a specific patient case. They said the entire system adheres to the new surprise medical bill law.

New York-Presbyterian Healthcare System patients also receive a letter that lists the companies and organizations involved in billing, along with contact information to ask for more details, a hospital spokesman said.

The letter also touches on how other businesses affiliated with the hospital charge for services.

Addressing the anesthesia group, the letter reads: "They make every effort to bill your insurance company for the professional fees of their Board-certified anesthesiologists. They accept assignment from Medicare and participate with many managed care companies and HMO's. Call prior to surgery to inquire about your insurance coverage."

Westchester Anesthesiologists, the group in Rye Brook, did not respond to a request for comment about how it charged Roberts.

Roberts said the surgery was planned, and she was never told about the potential for out-of-network charges. "If I was told about that, I would have refused and said find somebody in-network," she said.

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