New York seeks physician help with out-of-network confusion

As regulators cope with complaints about surprise bills, organized medicine wants to ensure that lawmakers don’t shift the hassle of network participation issues onto doctors.

By Emily Berry — Posted March 27, 2012

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

Insurance regulators in New York say doctors should be among those helping to eliminate what they say is one of the most common sources of complaints to the state: surprise bills from out-of-network physicians.

In a report released March 7, the New York State Dept. of Financial Services outlined how it believes physicians, insurers and hospitals’ practices contribute to more than 2,000 out-of-network billing complaints the state received from patients in 2011.

Among the solutions proposed in the report is to increase the responsibility nonparticipating physicians bear when they care for a patient. A lead surgeon, for example, might have to warn a patient about an assistant surgeon who is not part of the patient’s insurance network.

The Medical Society of the State of New York has worked with state officials to address problems with out-of-network payments. Physicians still want to help solve the problem, but don’t want to see the hassle simply handed from patients to physicians, said Moe Auster, vice president of legislative and regulatory affairs for MSSNY. The public and policymakers need to understand physicians are not creating the problem, he said.

“If anyone is at fault, health plans started this,” Auster said. “I’m not sure the public does understand it. They see it as ‘Clash of the Titans.’ They view the doctor and health plan on equal footing, when in most cases the health plan has the leverage.”

Based on a review of more than 2,000 complaints to the state’s financial services department in 2011, the report outlines problems with how out-of-network care is paid, and a solution for each:

  • Patients can’t effectively compare insurance plans because they don’t understand how out-of-network benefits are calculated. The report’s authors suggest insurers should give consumers examples of how much they will pay for a specific set of services provided outside the network, allowing for apples-to-apples comparisons between policies.
  • Because of out-of-date listings for network physicians, patients have a hard time shopping for the right doctor or comparing prices for care. The report suggests doctors, hospitals and insurers need to be able to tell patients when a non-network physician will be involved in their care and what those services will cost the patient.
  • A few doctors appear to be taking advantage of patients who need emergency care by charging far more than they accept for the same services in-network or from Medicare. The report suggests this kind of overcharge should be illegal, and there should be an independent process to identify excessive charges.
  • Not all patients are protected from the problem of inadequate networks, and are pushed into paying for more costly out-of-network care. The report suggests PPO enrollees should pay in-network prices if they must go outside their network because an appropriate specialist is unavailable nearby.
  • Insurers and employers have been paring back out-of-network benefits, which has taken some patients by surprise. The report suggests a possible minimum level of coverage required for plans that claim to provide out-of-network benefits.
  • Submitting claims for out-of-network care is complicated. The report suggests claims submission should be simplified and available online.

None of the recommendations in the report had been written into proposed legislation as of mid-March. Members of MSSNY planned to meet with legislative leaders and members of Gov. Andrew Cuomo’s administration at a planned forum, with the state’s regulation of out-of-network care a topic of discussion.

Whatever the resolution, it is likely to have national implications, as did the state’s previous push for reform in the way out-of-network care is arranged and paid for, Auster said.

When he was New York state’s attorney general, Cuomo took on the problem of out-of-network payment rates. A settlement in the state over how insurers calculate “usual, customary and reasonable” fees resulted in payment for a given service based on publicly available data rather than health plans’ number crunching. Many plans adopted that standard nationwide following the New York settlement in 2009, around the time a lawsuit against UnitedHealth Group was being settled for $350 million over its out-of-network practices with physicians.

That case was filed in 2000 in U.S. District Court in New York by the Litigation Center of the American Medical Association and the State Medical Societies, the Medical Society of the State of New York and the Missouri State Medical Assn. on behalf of out-of-network physicians. A judge in February approved the mailing of settlement checks to doctors who were affected.

In neither case did the companies admit any wrongdoing.

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn