ALBANY, N.Y. (AP) — New York hospital patients would no longer wake from surgery with the bad surprise of big bills from an anesthesiologist outside their insurance networks under legislation unveiled this week by the Cuomo administration.
Instead, they would not be responsible for bills normally not covered by their health insurance companies in both emergencies and in situations like scheduled surgeries where they weren't told that the anesthesiologist, radiologist or other specialist involved wasn't part of their insurer's network.
It would be left to the insurance company and doctor or hospital to resolve those billing disputes, with unresolved matters sent to an independent arbitrator.
"It's the No. 1 complaint we get at the Department of Financial Services," Superintendent Ben Lawsky said. His agency, which regulates New York insurers, has been dealing with the issue for two years, talking to stakeholders, he said. The bill was unveiled in supporting documents to Gov. Andrew Cuomo's proposed budget.
Unreimbursed out-of-network bills leave patients thousands of dollars in debt and can drive them into bankruptcy, Lawsky said. Arbitration between insurers and medical providers, modeled after the process used by Major League Baseball, would require arbitrators consider certain factors and choose one side's proposal or the other, an approach that's hoped to brings both sides closer together, he said.
"Patients are complete collateral damage in the wars between carriers and providers," said Elisabeth Benjamin of the Community Service Society, which receives complaint calls at its help line. "It just happens all the time. The patient has the least amount of bargaining power."
In one case, a patient was stuck with a bill for a mystery anesthesiologist and that doctor's helper for more than $20,000, Benjamin said. The problem for patients is huge, as the solution would be, she said.
Under the legislation, insurers would have to permit access to out-of-network providers if no one within their network has appropriate training and experience to meet the patient's needs. The bill would take effect immediately if enacted.
Leslie Moran of the New York Health Plan Association, an insurers' group, said it supports the proposal to protect patients against getting surprise bills. However, the group also hopes consumers will be protected against so-called "balance billing" by doctors. That's where the insurer reimburses, for example, 80 percent of what it considers an appropriate doctor's bill, then the doctor bills the patient for the remaining 20 percent plus the balance of whatever he says his service is worth.
"The balance billing issue had been a problem and continues to be," Moran said.
Elizabeth Dears, senior vice president of the Medical Society of the State of New York, said the group, which represents doctors, applauds Cuomo for moving the conversation forward with a strong proposal, but it's a complex issue involving additional disclosure, notice requirements and coverage. It's been a growing problem for their patients, with insurers restricting networks and arbitrarily lowering coverage amounts, and doctors having to absorb greater costs, she said.
The group wants to be sure the process is fair and doesn't give insurers the ability to simply pay doctors whatever they decide, Dears said. One issue concerns specialists agreeing to remain on call for emergencies. "There's a large number of people we need to talk to before we come up with an absolute position," she said.