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What to do when you get medical bills from out-of-network doctors

A new law gives you special protection from surprise bills and bills for emergency services from doctors who turn out to be out-of-network. Some of these bills can be adjusted, so you only pay for the cost of in-network care.

An out-of-network doctor or provider is someone who gives you care, but is not in your health benefit plan network. It's sometimes called a non-participating (or non-par) doctor. This type of care can cost you much more.

Your bill might be a surprise bill:

  1. If you got a procedure at a hospital or surgery center that is in network. But while you were there, you also got care from a doctor who doesn't participate in your network because:
    • A participating doctor wasn't available.
    • You didn't know you were getting care from a doctor not in your network.
    • A medical need that you or your doctor(s) did not expect required you to get care from an out-of-network doctor.
  2. If you were referred by a participating doctor to an out-of-network doctor or other health care provider. And you didn't sign a consent to show you understood there may be extra cost to you. A referral occurs when:
    • You get care from an out-of-network doctor in the same office, during your visit to the network doctor.
    • The network doctor takes a specimen (example: blood or tissue sample) that's sent to a lab or pathologist that is not in your network.
    • You are referred to an out-of-network doctor by a network doctor when referrals are required under your plan.

It's NOT a surprise bill if you choose to receive services from an out-of-network doctor when a network one is available.


Bills for out-of-network emergency services

The new law also protects you from bills for out-of-network emergency services. If you have coverage through an HMO or from any insurer subject to the laws of New York, you should not have to pay more than your in-network copayment, coinsurance or deductible for emergency hospital or ER care.


What to do if you get one of these bills

  1. Call us at the number on your ID card if you need help figuring out if your bill qualifies as a surprise bill or if it's a bill for emergency services for out-of-network medical care.
     
  2. For surprise bills, you’ll need to fill out an Assignment of Benefits form and send it to us and also the doctor.
     
  3. If it does qualify, we'll talk to the doctor or hospital to see if we can get them to lower the cost. If we can't come to an agreement, we'll dispute it using an independent dispute resolution (IDR) entity if it's an ER bill. Or your doctor will, if it's a surprise bill.
     
    You have the right to dispute it yourself. But often it's better to let us handle it — either directly with the provider or through the dispute process.
     
  4. Whichever party is making the dispute needs to go to the NY Department of Financial Services (DFS) website to get a file number and an IDR application.
     
  5. If Empire is disputing the bill, we'll send the application to the IDR entity on your behalf. If your doctor is disputing the bill, they'll send the application and your assignment of benefits form to the IDR entity on your behalf.
    If you're the one filing the dispute (please call us and let us know if you decide to do it on your own), you'll need to send the application and the assignment of benefits form to:
    NYS Department of Financial Services,
    Consumer Assistance Unit/IDR Process
    One Commerce Plaza, Albany, NY 12257
  6. Disputes are reviewed by IDR entities. Decisions will be made by a reviewer with training and experience in health care billing, reimbursement and usual and customary charges. They will consult with a licensed doctor in active practice in the same or similar specialty as the doctor providing the service that's the subject of the dispute.
     
  7. Decisions will be made within 30 days of receipt of the application. They'll notify you, your doctor, your health plan and New York Department of Financial Services.
     
  8. The law provides that the IDR entity must choose either the health plan's payment or the doctor's charge, based on what he or she determines is reasonable. The IDR entity's determination is binding upon the parties, which means that everyone must accept what they decide is right.
     
  9. Paying for the cost of IDR process:
    The doctor pays the cost of the dispute resolution when the IDRE determines that the health plan's payment is reasonable.
    The health plan pays the cost of the dispute resolution when the IDRE determines that the doctor's fee is reasonable.
    The doctor and the health plan share the prorated cost when there's a settlement.
    There may be a minimal fee to the doctor or health plan submitting the dispute if the dispute is found ineligible or incomplete.

If you have questions:

  • Log in to empireblue.com and select the Customer Service tab
  • Call Member Services at number on your ID card
  • Go to the NY Department of Financial Services website, or call them 1-800-342-3736
  • Email questions to IDRquestions@dfs.ny.gov

How you submit out-of-network claims and AOB forms:

  • Log in to empireblue.com
  • Go to the Message Center and select Compose Message
  • Follow directions to submit as an e-mail attachment or
  • Mail to:
    Empire Member Services
    P.O. Box 1407
    Church Street Station
    New York, NY 10008-1407

Out-of-network care usually costs you more

To make the most of your benefits, it's best to go to doctors in your Empire plan network. If your plan allows you to get care from an out-of-network doctor, you'll likely pay more out-of-pocket for that care.

See some examples of typical out-of-network costs under our three most common benefit plans in Manhattan.

Find out your out-of-network costs. Here's a link to a database from Fair Health, Inc. where you can estimate what costs to expect when you get out-of-network care. You can also log in and use our cost-estimator tool to see what your in-network costs could be. To make the most of your benefits, get care from your network of doctors and other health care providers.

 
 
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