Emergency Medical Services and Surprise Bills Law: Frequently Asked Questions

Overview

1. How does Public Health Law §24 prevent patients from getting surprise bills?

  • Subdivisions (1) through (2) apply to health care professionals in private practice and diagnostic and treatment centers, including health centers under 42 USC §254b. Diagnostic and treatment centers are health care facilities licensed under Public Health Law Article 28, including clinics, dialysis and ambulatory surgery centers.

  • Under subdivisions (1) and (2), health care professionals in private practice and diagnostic and treatment centers are required to disclose to patients or prospective patients in writing or through an internet website the health care plans in which they are participating providers and the hospitals with which they are affiliated and verbally at the time an appointment is scheduled. If they do not participate in a patient's health care plan, they must upon request from a patient inform the patient of the estimated amount they will bill absent unforeseen medical circumstances that may arise.

  • Under subdivisions (3) and (4), physicians in private practice also must provide information regarding any other health care provider scheduled to perform anesthesiology, laboratory, pathology, radiology or assistant surgeon services in connection with the care to be provided in the physician's office; and for scheduled hospital services, must provide information regarding other physicians whose services will be arranged.

  • Subdivisions (5), (6) and (7) apply to general hospitals as defined in Public Health Law §2801(10).

  • Under subdivisions (5), (6) and (7), a general hospital must post on its internet website its standard charges, the health care plans in which the hospital is a participating provider, and the physician groups that the hospital has contracted with to provide services and the physicians employed by the hospital.

  • Hospitals must also provide patients with additional instructions in advance of non-emergency hospital services through registration or admission materials. These materials must include a statement advising the patient to check with the physician arranging the hospital services to determine any other physician whose services will be arranged by the physician, whether it is anticipated that physicians who are employed or contracted by the hospital are reasonably anticipated to provide services to the patient (including anesthesiology, pathology and/or radiology), and how a patient or prospective patient can timely determine the health care plans participated in by physicians who are employed or contracted by the hospital and who are reasonably anticipated to provide services to the patient.

2. When did Public Health Law §24 become effective?

  • It became effective on March 31, 2015 and it applies to health care services provided on and after such date.

3. Does the Department of Health have plans to promulgate regulations regarding Public Health Law §24.

  • No, not at this time.

4. What does "employed" mean in Public Health Law §24?

  • Public Health Law §24 does not define "employed." The Department believes that 26 CFR §31.3121(d)-1(c) provides a generally accepted test for determining who are employees.

Health Care Professionals in Private Practice

5. What types of health care professionals does Public Health Law §24 apply to?

  • Any health care professional in private practice that is appropriately licensed, registered or certified pursuant to Title 8 of the Education Law. These health care professionals would include, but not be limited to, physicians, dentists, nurse practitioners, nurse midwives, podiatrists, mental health practitioners and physical and occupational therapists.

6. Must health care professionals in private practice who are not physicians comply withPublic Health Law §24?

  • Yes, subdivisions (1) and (2) apply to all health care professionals in private practice.

  • Subdivision (3) and (4), however, are requirements that apply only to physicians in private practice.

7. Can health care professionals comply with PHL §24(1) by posting the required information in their offices?

  • Yes, provided that a copy of the information is available upon request.

Physicians in Private Practice

8. Are physicians, required to provide a patient with the name, practice name, mailing address and telephone number of any health care provider scheduled to perform any services in connection with care to be provided in the physician's office or coordinated or referred by the physician?

  • Public Health Law § 24(3) requires a physician to provide a patient or prospective patient with the name, practice name, mailing address and telephone number of any health care provider scheduled to perform anesthesiology, laboratory, pathology, radiology or assistant surgeon services in connection with care to be provided in the physician's office or coordinated or referred by the physician for the patient at the time of referral to or coordination of services with such provider.

  • This disclosure, while recommended for all services, is only required by Public Health Law § 24(3) for the specific services listed. However, it will be a surprise bill under Financial Services Law § 603(h) if the physician participates with the patient's health plan and refers the patient to a non-participating provider (for any services) without the patient's explicit written consent acknowledging that the participating physician is referring the insured to a non-participating provider and that the referral may result in costs not covered by the health plan.

  • See http://www.dfs.ny.gov/consumer/hprotection.htm for more information regarding protection from surprise bills under Financial Services Law Article 6.

9. Under Public Health Law §24(4), does a physician arranging for a patient's scheduled admission to a general hospital have to disclose the actual names of other physicians that will be providing services or can they just provide information regarding the group practice of the other physicians?

  • The arranging physician may not know in advance which member of a group practice will be providing services. If the physician arranges for a specific physician in a practice, the physician must disclose the name, mailing address and telephone number of the individual physician. But if the physician only arranges for an unspecified member of the group practice and it is up to the group practice to schedule the individual physician, the physician arranging for the services need only disclose the practice name, mailing address and telephone number. The law also requires the arranging physician to include information on how to determine the plans that the other physicians participate in.

General Hospitals

10. What type of health care facilities does Public Health Law §24 apply to?

  • Diagnostic and treatment centers and general hospitals licensed under Article 28 of the Public Health Law. "Diagnostic and treatment centers" include, for example, clinics, dialysis and ambulatory surgery centers. The law does not apply to nursing homes, assisted living facilities or home care services agencies, for example.

11. Does a general hospital have to list physicians by name under Public Health Law §24(6)?

  • Public Health Law § 24 requirements apply to general hospitals that have a contract with physician groups and physicians who are employees of the hospital.

  • Public Health Law § 24(6)(c) requires hospitals to post the name, mailing address and telephone number of physician groups that the hospital has contracted with to provide services. The hospital is not required to list the specific physicians in the groups by name.

  • If a hospital contracts with individual physicians to provide services such as anesthesiology, pathology or radiology services in a hospital, the hospital should also disclose the name, mailing address and telephone number of those physicians.

  • Public Health Law § 24(6)(d) requires hospitals to post the name, mailing address and telephone number of physicians employed by the hospital and the health plans in which they participate. This includes physicians employed full time or part-time by a hospital. The hospital is required to list the employed physicians by name.

  • The hospital disclosure requirements regarding employed physicians apply regardless of whether or not the services will be billed by the hospital or the employed physician. However, if the services will be billed by the hospital, and the employed physicians participate in the same health plans as the hospital, the hospital may list the physicians, provide one address for contacting the physicians, provide one list of health plans, indicate that the physicians participate in the same health plans as the hospital, and provide a statement that the physicians will not bill separately for their services.

12. Under Public Health Law §24(5), general hospitals must make public, to the extent required by federal guidelines, standard charges. What is the extent of this required by federal guidelines?

  • Under federal guidelines, hospitals are allowed to either make public a list of their standard charges or their policy for allowing the public to view a list of those charges in response to an inquiry. See 79 Fed. Reg. 50145-50146 (August 22, 2014), implementing section 2718(e) of the Public Health Service Act (42 USC §300gg‑18(e)).

  • In addition, note that under Public Health Law §2807-k(9-a), hospitals must make public their financial aid policies and procedures. This law provides information and potential assistance to persons who are uninsured or underinsured.

13. Is it still possible that a patient would not receive information in advance about a physician rendering services at a hospital?

  • Yes, for example, this situation could occur if a physician with privileges at the hospital, who is neither an employee nor a physician or physician group the hospital has contracted with to provide services, provides services to a patient. In this case, the general hospital is not required to provide information about the physician under Public Health Law §24(6).

  • Thus, a bill received by a patient for services rendered by a non-participating physician in a participating hospital or ambulatory surgical center when a participating physician is unavailable, or a non-participating physician renders services without the patient's knowledge, or when unforeseen medical services arise may be a "surprise bill" under Financial Services Law §603(h). See http://www.dfs.ny.gov/consumer/hprotection.htm for more information regarding protection from surprise bills under Financial Services Law Article 6.

14. If a hospital has arrangements with individual physicians (not group practices) to provide on-call coverage (for example, in the emergency department one weekend a month), must the hospital disclose the name, address and telephone number of these physicians under Public Health Law §24(6)?

  • Yes, if the individual physician is a hospital employee.

  • No, not if the physician has hospital privileges but is not an employee of the hospital and the hospital has not contracted with the physician to provide services.

15. When a patient has an unscheduled admission to a general hospital (through the emergency department, for example) and is stabilized but requires additional inpatient treatment, how does Public Health Law §24 apply to physicians who treat the patient after stabilization?

  • The Public Health Law §24(1) verbal disclosure requirement would not be applicable because there was not a scheduled appointment. The physicians could satisfy the Public Health Law §24(1) written disclosure requirement by posting the information on their website. In such cases, physicians would not be required to provide a written disclosure to patients in the hospital.

  • With respect to the Public Health Law §24(2) disclosure requirements, physicians that provide non-emergency services to a patient in the hospital following a non-scheduled hospital admission may not know what health plan their patient is covered under, unlike when the patient schedules an appointment with the physician. In such cases involving hospital services, the physician would not have to make a disclosure to the patient, unless the patient specifically requests the information from the physician.

  • Public Health Law §24(4) is not applicable either, because the treatment was not scheduled prior to admission.

  • A patient may receive a "surprise bill" under Financial Services Law §603(h). See http://www.dfs.ny.gov/consumer/hprotection.htm for more information regarding protection from surprise bills under Financial Services Law Article 6.

16. Are faculty practice physicians employed by a medical school considered hospital employees?

  • No, if physicians are not employees of the hospital, they are not considered hospital employees for purposes of Public Health Law § 24.

17. Does a general hospital have to list medical residents by name under Public Health Law §24(6)?

  • If medical residents are not yet physicians or are not employees of the hospital, they are not physicians employed by the hospital under Public Health Law § 24(6).

Hospital Outpatient Clinics

18. Does subdivision (7) of Public Health Law §24 apply in a general hospital's article 28 clinic (an outpatient clinic operated by a general hospital)?

  • Yes, if a hospital provides patients with registration or admissions materials in advance of outpatient clinic services, such as outpatients registering for ambulatory surgery, it should include the information required by subdivision (7) of Public Health Law §24.

  • If a hospital does not provide such materials in advance of outpatient clinic services, the hospital should post this information in outpatient service areas or through a hospital website.

19. How should an outpatient facility that is owned by a general hospital comply with PHL §24?

  • The outpatient facility must comply with PHL §24 either as a general hospital or as a diagnostic and treatment center.

  • Any registration or admission materials must contain the information required by PHL §24(7) and include a statement advising the patient to check with the physician arranging the hospital services to determine any other physician whose services will be arranged by the physician, whether it is anticipated that physicians who are employed or contracted by the hospital are reasonably anticipated to provide services to the patient (including anesthesiology, pathology and/or radiology), and how a patient or prospective patient can timely determine the health care plans participated in by physicians who are employed or contracted by the hospital and who are reasonably anticipated to provide services to the patient.

20. When a general hospital outpatient is receiving an ongoing course of treatment requiring multiple visits (for example, pain management services) over a period of time, must the hospital provide information under Public Health Law §24 in advance of every visit?

  • Public Health Law § 24 does not stipulate how often a patient undergoing ongoing treatment must be provided information. The New York State Department of Health (NYSDOH) recommends that the required information be provided prior to the first visit and not in advance of every visit if the information required to be provided has not changed and the patient has received treatment for the same condition within the previous six months. If, however, the patient has not received treatment within the previous six months, the NYSDOH recommends the hospital consider providing information in advance of each visit even if the information to be provided has not changed.

Disclosure of Health Plan Products

21. Is a health care professional, group practice of health care professionals, diagnostic and treatment center or hospital required to list the specific lines of business of a health plan and the health plan products in which it participates?

  • Public Health Law § 24(1) and (6) require health care professionals, a group practice of health care professionals, diagnostic and treatment centers and general hospitals to disclose the health plans in which they are participating providers.

  • If a health care professional, a group practice of health care professionals, diagnostic and treatment center or a hospital participates with all lines of business or products of a health plan, it is sufficient to state that it participates with all lines of business or products without listing the specific lines of business or products.

  • If a health care professional, a group practice of health care professionals, diagnostic and treatment center or a hospital participates with some but not all lines of business or products of a health plan, they should list the specific line of business or products to the extent the information is available. The information will be considered available if it is in the provider contract that the health care professional, a group practice of health care professionals, diagnostic and treatment center or hospital signed with the health plan. It is sufficient to use the descriptions of the line of business or products included in the provider contract.

  • If a health care professional, a group practice of health care professionals, diagnostic and treatment center or a hospital does not participate with any lines of business or products of a health plan it may either: (1) state that it does not participate with any lines of business or products of the health plan without listing the specific lines of business or products; or (2) omit a reference to that particular health plan in its written or website disclosure.

  • A health care provider should make a good faith effort to provide a patient with information that the patient can use to determine whether the health care provider is a participating provider for the health insurance plan that the patient is enrolled in.

Other

22. How does Public Health Law §24 apply to clinical laboratories?

  • Under Public Health Law §24(3), a physician must provide a patient with the name, practice name, mailing address and telephone number of any health care provider scheduled to perform laboratory services. Clinical laboratories are not themselves required to comply with Public Health Law §24.

Complaints

23. What should a patient do if they receive a surprise bill or they would like to file a complaint that a physician, physician assistant or specialist assistant, or a general hospital or diagnostic and treatment facility has violated the requirements of Public Health Law §24?