NEW YORK -- Hospital patients in New York state are the latest in the nation to gain legal protection against unexpected bills from doctors who won't accept their insurance.
New York this week extended patient protection laws to restrict out-of-network providers from "balance-billing" consumers for emergency care or when patients can't choose their doctors. Balance-billing occurs when health workers who don't accept a patient's insurance try to collect the difference between their charge and the insurer's reimbursement.
New York is one of 13 states that have restrictions on out-of-network balance-billing, according to the Kaiser Family Foundation. Patients most often receive these surprise bills in emergency cases, when they can't choose the doctors who treat them. In California, a 2007 survey conducted before the state implemented patient protection laws found 1.8 million insured residents who visited emergency rooms over two years faced extra charges, according to the California Health Plan Association.
"It's a pretty good bet that if you're hospitalized or having any kind of surgery, somebody along the way who touches you or your slides or films will not be in network," said Karen Pollitz, a senior fellow at the Menlo Park, Calif.-based Kaiser foundation.
New Yorkers previously were protected only from out-of-network ambulance bills and, for individuals in health maintenance organizations, in the ER. Under the new law, beginning next year all medical providers will have to notify patients before treatment if they don't take their insurance. If not, patients will be required to pay only a regular copay as if the provider was in network.
Balance-billing happened to Abby Ives, a therapist and clinical social worker from Ossining, N.Y., when she fell in her front yard on June 24, 2012, and shattered a bone in her right leg.
As a health care provider, Ms. Ives, 61, knew the importance of insurance.
"As I was laying in the front yard, I told my husband, 'Honey, get the insurance card, we're going to need it,' "she recounted in a telephone interview.
The ambulance took her to Phelps Memorial Hospital Center in Sleepy Hollow, which was covered by her insurance through Empire Blue Cross Blue Shield. Ms. Ives underwent surgery, then X-rays revealed her left leg also was broken, so she had a second surgery. During her monthlong stay in the hospital, she said, she wasn't told that many of the providers treating her weren't included in her insurance plan.
Ms. Ives was shocked when, after she was discharged, Empire notified her that both surgeons, the hospitalists who coordinated her care within the hospital and the cardiologists who read her electrocardiograms, weren't part of her coverage plan. One surgeon sent her a bill for $13,000, the hospitalists charged $1,500, and two electrocardiograms were an additional $100 each. Hospitalists are physicians whose practice focuses on the care and treatment of acutely ill people in hospitals.
To pay the bills, Ms. Ives said, she would have to reach into her and her husband's retirement funds. She appealed to the surgeon's billing staff repeatedly, she said, before the surgeon agreed to accept the insurance company's out-of-network reimbursement of $20,000 and stop pursuing Ms. Ives for the balance of $13,000.