Protection from Surprise Medical Bills: The New Healthcare “Out of Network Law”

Sep 25, 2015




The area of healthcare has received much attention on the national stage for a number of years now.  In 2013, total healthcare spending was about $2.9 trillion and made up approximately 17.4% of the US Gross Domestic Product (GDP), the highest of any developed country in the world. However, outcomes in the United States are less favorable than any other developed nation. This is the only industry where no one knows what the price is for the services they are receiving until weeks after receiving that service.  For too many Americans, these costs cause significant financial distress, and are one of the leading reasons for personal bankruptcy.

healthcareaOn March 31st, the State of New York made effective the Out of Network Law, some of the first legislation that will help to ease the financial burden and allow users of healthcare services a clearer understanding of what services will cost – to better estimate the consumers’ financial responsibility.  The Out of Network Law (OON) provides for the following:

1) A hospital must post on its website, to the extent required by federal guidelines, a list of the hospital’s standard charges for items and services provided by the hospital.  Additionally, it also requires a listing of all the health plans with which the hospital participates, a listing of employed and contracted physicians, as well as the contact information for these physicians.  If the hospital participates in some, but not all lines of business within a health plan, they must disclose the specific line of business or product that it participates in.  The facility must also make public their financial aid policies and procedures, allowing information to those who are uninsured or underinsured.

2) A consumer will not be charged the out-of-network cost for a surprise bill if they did not have the opportunity to avoid it and stay in network. All health plans must cover at the in-network cost any out-of-network provider bill for emergency services, as well as:

A. Surprise non-emergency bills for physician services in a hospital or surgical facility when an in-network provider is unavailable.

B. When the consumer was not informed in advance (a non-participating physician provided services without the patient’s knowledge).

C. When a physician refers the consumer to any out-of-network provider and the consumer did not provide written consent acknowledging the out-of-network services, resulting in costs not covered by their health plan.

3) Enhanced consumer disclosures from insurers, doctors and hospitals, allowing consumers to more easily know which providers are out-of-network, how much those providers expect to charge, and how much the insurer expects to cover. Those disclosures will help prevent consumers from getting hit with surprise bills in the first place. In addition, all health plans will have to meet minimum standards for adequate provider networks before offering coverage. And all health plans must allow the consumer to go to an out-of-network provider at the in-network cost share if the insurer does not have an appropriate in-network provider, as decided by an independent review. The law also makes out-of-network claim submissions easier for consumers, among other protections.

Navigating the world of healthcare can easily become an overwhelming process, and as a patient or caregiver – having the additional worry of unknown billing can take the focus away from the primary goal of improving you or your loved-ones condition.  I believe this law goes a long way in helping consumers understand the expenses incurred for their healthcare, while also preventing them from having to bear additional costs.   However, it does not answer the much larger issue of healthcare spending increases, and how to control that so healthcare can become affordable to all.  I believe that debate will continue into the foreseeable future.



Post by Kaitlin Alfvin

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