The NY Department of Financial Services (DFS) recently announced it is amending the NY surprise billing law to “apply federal requirements to the NY IDR process.” As previously reported, in 2020, Congress adopted the No Surprises Act (NSA) which becomes effective for plan years starting on or after January 1, 2022. Under the NSA, out-of-network providers are prohibited from balance billing patients for certain types of services covered under the NSA unless a notice and consent is signed by the patient for post-stabilization care under limited circumstances or when the patient elects to use an out-of-network provider.
Changes to the New York Surprise Bill
The changes to the NY surprise bill to apply the NSA requirements will expand and/or modify specific provisions of the state bill including but not limited to:
- Types of Providers Eligible for NY IDR: broadens the criteria from physicians to “physicians and providers”.
- Types of Services Eligible for IDR: expansion of applicable items and services under the federal term “visits” such as equipment and devices, preoperative and postoperative services, etc.
- Exempt Emergency Services CPT Codes: elimination of NY Law exemptions for CPT Codes (99281-99285, 99288, 99291-99292. 99217-99220, 99224-99226, and 99234-99236). The federal legislation does not include an exemption for any American Medical Association current procedural terminology (CPT) codes.
- Covered Patient Cost-Sharing Under NY IDR Process: beginning on January 1, 2022, an insured’s cost-sharing should be calculated based on the issuer’s original payment amount and cannot increase based on the IDR entity’s determination.
- Waiver of Balance Billing Protections for Emergency Services: Provisions relating to notice and consent and waiver protections from emergency services after the covered patient is stabilized do not apply in NY.
- State-Developed Model Notice: NY has developed a notice that complies with both federal and state requirements and encourages providers and facilities to use this form.
New York’s Independent Dispute Resolution Process
The NY surprise billing law and its IDR process have been heralded for providing a balanced approach that protects patients while offering a reasonable payment dispute process between providers and insurers. Amending the state bill to incorporate regulations from the NSA will limit the number of claims subject to the federal NSA either in whole or part since the NSA defers to state laws where applicable. Despite recent legislative challenges to the NSA IDR process and in particular, the qualifying payment amount (QPA) as the presumptive payment amount for providers, New York is taking action to expand the number of claims that will qualify under the state’s statute before the federal legislation becomes effective next week.
Contact Cohen Howard to Learn More About New York’s Surprise Bill Law
We expect that other states with existing comprehensive surprise billing laws will follow New York’s lead to amend their bills. We remain committed to crafting effective strategies to maximize your payments from payors for all your claims. Please contact us should you like to specifically discuss your practice and the implications of the new regulations.