New York IDR Arbitration For Medical Revenue Recovery

New York Surprise Billing Law (SBL)

The New York Surprise Billing Law (SBL) became effective in 2015 and is codified under Financial Services Law Article 6 and 23 NYCRR 400. It establishes reimbursement standards and arbitration procedures for out-of-network (OON) services in specific situations, protecting patients from surprise medical bills.

Key Provisions of the New York SBL

1. Reimbursement Standard:
   • OON services must be reimbursed at a "reasonable" amount.
2. Arbitration Timeline:
   • Arbitration claims can be initiated within 3 years from the date of payment.
3. Use of Usual, Customary, and Reasonable (UCR) Data:
   • UCR data can be submitted during arbitration and is often the prevailing metric used in decision-making.
4. Provider Billing Consistency:
   • Medical providers must maintain their billed charge for a particular CPT code as their demand amount for arbitration.
5. Exclusion of NYSHIP:
   • The New York State Health Insurance Program (NYSHIP), which provides coverage for New York State employees, has opted out of the state arbitration process. Disputes involving NYSHIP are resolved under the federal independent dispute resolution (IDR) process.

Scope of Application

The New York SBL governs OON reimbursement for:

• Emergency Services:
  • Provided by nonparticipating emergency facilities or providers.
• Nonemergency Services:
  • Rendered by nonparticipating providers in hospital facilities or ambulatory surgical centers, including:
    • Cases where a patient receives a referral to a nonparticipating provider.
    • Inpatient services following an emergency room visit.

State and Federal Coordination

1. Specified State Laws:
   • New York's SBL applies to insured group health plans and individual health insurance coverage for services rendered by nonparticipating providers under the outlined circumstances.
   • For these cases, the federal IDR process under sections 2799A-1(c) of the Public Health Service (PHS) Act and 45 CFR 149.510 does not apply.
2. Federal Oversight for Excluded Cases:
   • Claims involving NYSHIP or other services not governed by New York’s SBL fall under the federal IDR process.

CMS Clarifications

In a letter from CMS to the Governor of New York (July 29, 2022), CMS provided the following details:

1. No All-Payer Model Agreement:
   • New York does not have an All-Payer Model Agreement to determine OON rates.
2. Application of State Laws:
   • Financial Services Law Article 6 and 23 NYCRR 400 are designated state laws for determining OON rates in applicable cases.
3. Federal Exemptions:
   • The federal IDR process applies to cases not covered under New York’s SBL, particularly those involving NYSHIP and other excluded scenarios.

This dual structure ensures comprehensive patient protection against surprise billing while delineating the responsibilities of state and federal arbitration processes.