N.Y. Law Offers Model For Helping Consumers Avoid Surprise Out-Of-Network Charges

by Michelle Andrews
Kaiser Health News, July 14, 2015

It’s a situation that occurs all too often: Someone goes to the emergency room and doesn’t learn until he gets a hefty bill that one of the doctors who treated him wasn’t in his insurance network. Or a diligent consumer checks before scheduling surgery to make sure that the hospital she plans to use and the doctors that will perform it are all in network. Then she learns later that an assistant surgeon who she didn’t know and who wasn’t in her network scrubbed in on her operation.

“If we’re mandating that people buy insurance coverage it seems we should also protect them from surprise medical bills,” says Mark Rukavina, from Community Health Advisors in Chestnut Hill, Mass.

If an out-of-network doctor or other provider doesn’t have a contract with a health plan that determines how much they get paid for services, they may bill the patient for any charges not covered by insurance. In those instances, the consumer could be on the hook for the rest of the bill, a practice known as “balance billing.” Although there’s no federal protection, about a quarter of states have laws on the books against balance billing by out-of-network hospitals, doctors or other providers in at least certain circumstances such as emergency care