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Notice of Emergency Adoption and Revised Rule Making

Notice of Emergency Adoption and Revised Rule Making for Independent Dispute Resolution for Emergency Services and Surprise Bills-New York State Register, April 1, 2015

 

Printed today (4-1-15) in the State register is a Notice of Emergency Adoption and Revised Rule Making for the Independent Dispute Resolution process for Emergency Services and Surprise Bills. The regulations which were first printed in the State register December 31, 2014 have been revised as outlined below. The regulations are effective March 31, 2015. However, there is an additional 30 day comment period on the new regulations.

This regulation implements the Independent Dispute Resolution (IDR) process for a dispute for a bill for emergency services or a surprise bill for non-emergency services. All decisions by the IDR entity (IDRE) must be made within 30 days. Health plans, providers, and uninsured patients are authorized to utilize this process. To view the regulation go to: http://www.dfs.ny.gov/legal/regulations/emergency/np400t.pdf

New York ACEP provided written comments on the December 31 regulations stressing the need to bundle substantially similar claims to keep the process manageable and the cost affordable. While the Department of Financial Services (DFS) declined to make this change in the revisions, they note in their comments in the State Register that the cost of the process was a concern to stakeholders. According to a recent conversation with officials at DFS, the cost of an appeal will range from $225 to $325.

 

The following revisions were made to the regulations, effective March 31, 2015:

  • When the IDR rules in favor of a health care provider, the health plan must pay the provider any additional amount owed within 30 days of the date of the determination.
  • Non-participating physicians are allowed at least 7 business days to respond to a health care plan’s offer.  
  • IDREs are prohibited from reviewing disputes when they acquire or become controlled by an advocacy group or association of providers or health plans.
  • Officers, directors, or managers of a physician’s medical group or independent practice association or health care facility are included when determining conflicts of interest for IDREs.
  • Reviewers are prohibited from handling a dispute when they have a conflict with an affiliate of the health plan involved in the dispute.
  • Health plans are only required to provide the insured with IDRE information when the plan pays less than the provider’s charge.
  • The period of time for physicians and health plans to submit examples of fee information to the IDRE is extended from 12 to 24 months.

In addition, DFS notes in the “Assessment of Public Comment” section that commenters requested a change in the regulations to permit multiple CPT codes if more than one is applicable to a patient. DFS responded that “The IDR process will review the services provided to patients, which may consist of one more CPT codes.”