Surprise!

Guess what!

Something new is happening in New York State. Disclosure requirements for providers. Here's the scoop:

Summary of New Disclosure Requirements for Providers

New York State Public Health Law Section 24

Effective 3/31/15

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Health care Professionals or Group Practice

Information to be provided in writing or on the health care professional’s website prior to the provision of non-emergency services:

·         The health care plans with which the provider participates [PHL § 24(1)].

·         The hospitals with which the health care professional is affiliated[PHL § 24(1)].

Verbal information to be provided at the time an appointment is scheduled:

·         The health care plans with which provider participates [PHL § 24(1)].

·         The hospitals with which the health care professional is affiliated[PHL § 24(1)].

Information to be provided when the Health Care Professional does not participate in the network of a patient's or prospective patient's health care plan:

·         Prior to the provision of non-emergency services, inform the patient or prospective patient that the amount or estimated amount the patient will be billed for health care services is available upon request [PHL § 24(2)(a)].

·         Upon receipt of a patient or prospective patient’s request, the amount or the estimated amount (in writing) the patient will be billed for health care services, absent unforeseen medical circumstances that may arise when the health care services are provided [PHL § 24(2)(b)].

There's more, like you need to be very specific when referring a patient to another provider, and there's stuff for hospitals, too.

This is the Emergency Medical Services and Surprise Bill, enacted because patients were seeing new doctors without realizing these doctors weren't in-network, and then getting stuck with an unexpected bill. A lot of times this happened because insurance companies have out-of-date in-network provider lists, so patients would go to someone on the list, thinking they'd be covered. Here's a link to a summary of the problem, published in 2012, An Unwelcome Surprise.

And here's an article from about a year ago, published in Families USA, New York’s New “Surprise Bill” Law Rolls out New Health Insurance Protections for Consumers , that summarizes the law. Basically:

Insurers have to keep their in-network lists up to date.

Providers need to inform patients of their network and hospital affiliations.

Providers need to tell patients they have the right to know what the bill will be like, and if the patient asks, the approximate amount, barring anything unforeseen.

You have to tell your patient how to find out how much their network will cover for any doctors you refer them to.

And analogous stuff for hospitals.

It also allows patients to get out of network care, at the expense of the insurance company, if there is no comparable inpatient care. And when there are disputes about the care that's available-like that would ever happen-these need to go through an independent review process.

And another part of the deal is that insurers need to guarantee adequate care be available in-network:

In New York, all health plans must now meet network adequacy rules to reduce the use of more expensive out-of-network medical services 

Notice that the purpose is to cut costs, not provide good care.

Notice, also, that the problem is precipitated by lack of out-of-network coverage, out of date network provider lists, and incomprehensible reimbursement rules.

So the obvious solution is to have the evil out-of-network doctors take over the responsibility of informing the patient that they're out-of-network, and figuring out how the patient can figure out what they'll be reimbursed.

I can understand how this law is helpful to patients, especially in settings like large group practices, where they get plied with impersonal bills. It has no place in a private psychiatric practice like mine. I don't have a website. I don't give new patients a clipboard with HIPAA forms and PHQ-9s and office policies in the waiting room. And I sure as shootin' won't have a bunch of legal rubes telling me how to talk to a new patient. As far as I'm concerned, therapy begins from the moment the patient picks up the phone to make an appointment. Interactions around payment are part of the treatment process, and whoever drafted the law doesn't have the training to dictate how therapy should be practiced.


Oy, so many battles. Remove Part IV of MOC, get a new certifying board, postpone e-prescribing for a year, get some out of network plans on the NY exchange. I'm exhausted. I was almost too exhausted to write this post, in fact, but then I had an idea.

What if I were to comply with this law the way contracts include unpleasant clauses, and drug ads disclose potential adverse effects? That's right, small print, and rapid, barely comprehensible speech, like on The Simpsons, in the commercial for Viagrogaine for baldness and impotence, at the end, the announcer says, "Possible-side-effects-include-loss-of-scalp-and-penis."

I participate in Federal United Care-Universal (FUC-U) plans. $17,000 per session. Rates are not guaranteed.