Seeking to rein in one of the more common patient complaints about medicine, New York’s 2014 budget agreement takes steps to shield consumers when an out-of-network provider steps in and provides care like radiology, anesthesiology, or pathology.
To tackle the problem, policymakers focused on doctors and insurers as the appropriate venue to resolve billing disputes, establishing an Independent Dispute Resolution (IDR) process.
When a patient receives services from an OON provider, the IDR will make a judgment about reimbursement, based on the physician’s charges, what the insurer would commonly pay, the physician’s experience, the complexity of the case, and the usual cost of the service.
Patients will be responsible only for the co-pay they would have paid an in-network provider.
IDR rulings are required to be issued within 30 days of the notice of a dispute, so providers won’t have to deal with the uncertainties of endless rounds of debate that drag on for months.
In addition, policymakers focused on greater transparency, requiring insurers by 2015 to reestablish “usual, customary and reasonable” (UCR) charges on which to determine reimbursement rates.
Patients will have greater flexibility to seek OON specialists when their provider networks don’t offer an appropriate option, with reimbursement based on UCR.
A working group comprised of physicians, insurance representatives, consumers, and co-chaired by the Superintendent and the Commission of the Department of Health will be responsible for improving access and adequacy of OON services and coverage.
These reforms address both longstanding issues that patients and providers have faced, and also anticipate future problems associated with the “narrow networks” of many plans purchased on the New York State of Health exchange.
We can help you understand the impact of these and other changes on your practice.
Call us today at (212) 577-6677 and schedule a consultation.