Not long ago I received an email from an acquaintance—let’s call her Jill— who was flustered about a bill she got from a doctor.
It seems Jill had been to her primary care physician for an annual checkup, and the doctor was concerned that her heart wasn’t beating quite regularly, so he referred Jill to a cardiologist he trusted. Jill went to the cardiologist, who examined her and administered an electrocardiogram (EKG), and concluded that everything was fine. At the cardiologist’s office, Jill paid her copay, and thought that was that. But three weeks later she received a bill for $495 from the cardiologist.
Jill called the office, and was told that although the cardiologist participated with her insurance company (Oxford), he didn’t participate with her particular plan (Liberty), and when she completed the new patient paperwork at the office she agreed to be responsible for any charges not covered by her insurance plan. Since her plan did not have out-of-network benefits, the carrier didn’t pay anything, and she was on the hook for the rest of the bill.
Needless to say, Jill was rather upset. After all, she had called the office and asked if the doctor participated with Oxford, and was told that he did. She felt that she was being held responsible for charges that the office bore some responsibility for, and she didn’t want to pay her bill.
Although I sympathized with Jill, she ordinarily would have been responsible for the charges. After all, she wasn’t specific in her questioning (namely, she didn’t ask if the doctor participated in her particular plan), and she didn’t check her benefits online to see if the doctor was in her network. Had she refused to pay the bill, the office could have—rightly—sent her to collections.
But Jill’s case was special, and she didn’t owe a penny, because she saw the cardiologist in Manhattan in June.
A few months ago, New York passed a law protecting patients in Jill’s situation. Called the Surprise Bill Law, it protects patients who get referred from an in-network provider to an out-of-network provider without being advised that their insurance benefits may not be the same. Had the primary care provider advised Jill that she was being referred to a non-participating specialist, she would owe all the money. But since she was not so advised, her financial liability was capped at the same amount that it would have been had she seen an in-network doctor. And since, in-network, her responsibility was only her copayment amount, that amount was all she owed her out-of-network cardiologist. Having paid her copayment at the time of service, Jill was off the hook for any further charges.
The cardiologist’s office could have protected itself, advising Jill that the doctor was not in her network, and thereby would be allowed to hold her responsible for the full amount. And no doubt the cardiologist’s staff would be more careful in the future (and probably would quickly advise the primary care provider’s office to do the same). But in this case, the patient’s rights won the day.
At the moment, there is no such law in New Jersey, so patients with in-network-only benefits should be careful when obtaining services from out-of-network providers. And the New York law has its flaws (such as penalizing the specialist in Jill’s case because of a notification that the other doctor was responsible for making). But this law is a big step forward in patient rights, and bills copying its protections are being considered by other states in the region.
Yossi Faber earned his MBA in Healthcare magna cum laude from the joint Mount Sinai School of Medicine—Zicklin School of Business program at CUNY Baruch. He is a member of two healthcare industry-focused networks of expert professionals, and is an invited lecturer at major medical centers and state medical societies. He founded and manages Clean Bill of Health (www.cleanbillofhealth.com), which provides both medical billing services to physicians as well as advocacy services for patients to review and help reduce the burden of their medical bills. Yossi lives in NJ with his wife and children.
