Healthcare is at the forefront of our national politics debate right now. Insurance companies have been playing hardball with hospital and medical providers. Insurance companies generate increasing revenues by paying out as little as possible on claims that they can. You may have noticed in your travels around Long Island, New York City and the Hudson Valley Region many smaller independent hospitals and doctors' practices have merged with larger health organizations. This is largely in response to decreasing insurance company reimbursement rates. A sole practitioner doctor or independent hospital does not have as much leverage in negotiating reimbursement rates with large insurers, as opposed to Northwell Health for example. These smaller medical providers join forces with a bigger healthcare group to take advantage of better insurance rates, greater negotiating power, and less administrative headaches.
Increasingly, especially with the largest insurance companies, insurers are out-of-network (meaning they do not have a contract) with your local hospital or medical provider. If you voluntarily, and knowingly, see one of these doctors in a non-emergency situation you may have significant out of pocket costs to pay that doctor. But what happens if you are forced to go to this hospital in an emergency situation? Your insurance company must pay for the services minus your co-pay or coinsurance. However, in our experience in hospital billing, insurance companies have not been following the law. Insurance companies are only paying their in-network rates to these out of network providers. The providers have no choice but to then pursue the patient for the balance of the claim.
What is the law governing this matter? Generally speaking, we will look at New York State Insurance Law Sections 3216, 3221, 3241(c), 3216(d). First, what exactly is the definition of an emergency situation? An “emergency condition” means a medical or behavioral condition that manifests itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (i) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy; (ii) serious impairment to such person's bodily functions; (iii) serious dysfunction of any bodily organ or part of such person;(iv) serious disfigurement of such person. Therefore, the standard of what is an emergency is rather low. If you experience for example, severe stomach pain, and you believe that pain could put you into serious jeopardy, it is very likely that constitutes an emergency (New York Insurance Law 3216(i)(9)(C)). The standard is one of reasonableness and common sense.
Furthermore, in an emergency situation your insurance company is prohibited from: (1) requiring prior authorization; (2) requiring that the healthcare provider participates in their network; (3) imposing a limitation on coverage or administrative requirement; (4) make the cost sharing requirements (co-pays or coinsurance) more than what would be paid if the health care provider was in network (New York Insurance Law 3216(i)(9)(A)) et seq.
So what happens If you are billed by a non-participating hospital or doctor in an emergency situation and your insurance company refuses to pay? You have options, show them that you are willing to fight them and be a knowledgeable consumer. The New York Department of Financial Services has helpful information on their website that can be accessed at http://www.dfs.ny.gov/consumer/hprotection.htm. If your insurance company absolutely refuses to protect you from out-of-network services you can file a complaint with the New York Department of Financial Services. They are the entity responsible for the regulation of health insurance companies in New York.