Business As Usual. And Customary.

Effective April 1, New York State has enacted a new law paving the way for New Yorkers with health care insurance to reduce the number of “surprise” bills. All too often, health care consumers with network coverage find out that the doctor they saw is no longer part of their health plan, or that the hospital they visited in-network employs out-of-network providers. These providers are then free to bill at full, retail rates, and expect to be reimbursed at out of network pricing, often including a healthy out of network deductible for the unsuspecting patient.

The legislation, entitled the “Emergency Medical Services and Surprise Bills” law, amends current New York Law and can be found at

Under the new law, New Yorkers can now appeal bills that they believed to be in network, leading to an independent resolution process that will allow payers and providers to settle disputes based on a database of “usual and customary” prices for the care delivered. This database is operated by Fair Health, an independent entity founded in 2009 to address potential conflicts of interest in the methods that health insurers were using to determine reimbursements to patients who received care from providers outside their health plans’ networks.

The Fair Health database ( ) tracks millions of insurance payments, and the Usual and Customary Costs benchmark is calculated for a range of services, usually 80% of the UCC. Under the newly-enacted law, payers or providers can initiate the process. To make things slightly more interesting, the losing party in the dispute pays the cost of the dispute resolution.

While the spirit of the law clearly intends to create some uniformity in billing, and to minimize the surprise billing incurred by the insured, the letter of the law places several new burdens on physicians, physician offices and clinics and hospitals in the paperwork and administration of the patient’s bill, including publicly posting the many plans they are currently accepting, adding yet more more cost to the system overall.

In the meantime, if you have insurance in New York State and receive a surprise bill for out-of-network care that you believed should be covered, be sure to let your insurance company know. And if you are without insurance? Don’t get sick. You probably can’t afford it.

(For a full rundown of the law and it’s associated impacts, see )