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Insurance Resources

iStock_000014494710XSmallNYSPA's Insurance Committee's Avenues for Seerking Help with Insurance Issues guide

NYSPA provides insurance resources as part of our commitment to allow members access to the most up-to-date information possible to support their practices. We hope this section will prove to be an invaluable tool and daily resource.

The information is regularly, addressing the most frequently asked and discussed topics on NYSPA’s listserve, and calls received at Central Office. Use the following link to access the weekly topics highlighted in the NYSPA Friday Flash newsletter in the 'Just Ask Me" section.  We invite members to share their knowledge and experience with colleagues by sending  suggestions and new information to This email address is being protected from spambots. You need JavaScript enabled to view it. .

This site also allows members to learn more about NYSPA's Insurance Committee and how they are helping shape the future and protect your interests as a psychologist.

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How To Opt Out of Medicare

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Sample CMS-1500 Form for Medicare (NGS) Claims

Sample HCVA 1500 for Medicare (NGS) claims

Updated Form CMS-1500 Information

Effective Date: October 1, 2010
Related CR Transmittal #: R1970CP
Implementation Date: October 4, 2010

Provider Types Affected

This is an informational article for physicians, providers and suppliers who use the Centers for Medicare & Medicaid Services (CMS) CMS-1500 claim form to submit claims to Medicare contractors (carriers, Part A/B Medicare administrative contractors [A/B MACs], and durable medical equipment [DME MACs] for services provided to Medicare beneficiaries.

What You Need to Know

This article, based on Change Request (CR) 6929, updates the CMS-1500 claim form information in the CMS Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual by removing language allowing the use of legacy identifiers and making other technical corrections as a result of that change. As part of this update, providers are reminded that they are responsible for purchasing their own CMS-1500 claim forms. Forms can be obtained from printers or printed in-house as long as the forms follow the specifications approved by the CMS as developed by the American Medical Association. Photocopies of the CMS-1500 claim form are not acceptable. Medicare will accept any type (i.e., single sheet, snap-out, continuous feed, etc.) of the CMS-1500 claim form for processing. You may purchase forms from the U.S. Government Printing Office by calling 202-512-1800.

Additional Information

The official instruction issued to your Medicare carrier and/or MAC regarding this change may be viewed at http://www.cms.gov/Transmittals/downloads/R1970CP.pdf  (200 KB) on the CMS Web site.

Governor Cuomo Announces Department of Financial Services Investigation into Out-of-Network Medical Costs Affecting New Yorkers Across the State

Report Finds Overwhelming Need For More Transparency and Better Consumer Protections So Consumers Stop Getting Surprise Bills

[1]
Albany, NY (March 7, 2012)

Governor Andrew M. Cuomo today announced that the Department of Financial Services (DFS) is investigating unexpected out-of-network medical costs affecting New Yorkers across the state, many of whom cannot afford to pay out-of-pocket expenses. In addition, DFS released a report that finds an overwhelming need for increased transparency from insurers and medical service providers, and improved consumer protection measures to ensure that New Yorkers stop receiving unexpected bills.

The investigation was sparked by an overwhelming amount of consumer complaints. DFS found that unexpected out-of-network medical bills are one of the most common complaints received by the agency.

New Yorkers can read the report at http://www.governor.ny.gov/assets/documents/DFS%20Report.pdf [2] .

“The high cost of health insurance and health care are an enormous burden for most New Yorkers,” Governor Cuomo said. “Our investigation shows that too many people are being hit with medical bills that are too high when they thought their care was covered by their insurance. We can’t allow that to continue. We must work with the insurance companies and medical service providers to ensure that all New Yorkers fully understand and are aware of the terms of their healthcare contracts.”

Financial Services Superintendent Benjamin M. Lawsky said, “Our report shows that all too often people who try their hardest to stay in network still get stuck with the most unwelcome surprise -- a big out of network bill. We need to reform our system now to protect middle class New Yorkers who can least afford these additional burdensome costs."

Sherry Tomasky, Advocacy Director of the American Cancer Association, said, "This is a widespread problem that particularly plagues cancer patients. New Yorkers who are dealing with the stress and anxiety of being treated for cancer should not have added burden of thinking about unexpected exorbitant costs that they cannot afford. I applaud Governor Cuomo and Superintendent Lawsky for their leadership on this issue and look forward to working with them on righting these wrongs."

Elisabeth Benjamin, of Health Care for All New York and Vice President of Health Initiatives at the Community Service Society of New York, said, "HCFANY is delighted that the Department of Financial Services has conducted this important investigation of surprise out-of-network bills. For far too long, it is the patient who is snared in the inscrutable billing bureaucracy between providers and insurers. The Department’s investigation highlights this problem, and HCFANY stands ready to help come up with a real solution that works for New York’s patients.”

The Department’s report produced the following findings:

Too many unexpected bills: DFS found many cases where a consumer does everything possible to use an in-network health care provider for non-emergency services, but nonetheless receives a bill from a specialist (often a radiologist, anesthesiologist, or lab) whom the consumer did not know or realize was out-of-network.

One case involves a child who had open heart surgery. The child’s parents were not told an assistant surgeon would be involved in the procedure and that assistant surgeon was out-of-network. The family was forced to pay $5000 of that doctor’s $6400 bill.

Another case involves a patient who was sent an unexpected $1300 bill for what turned out to be an out-of-network anesthesiologist.

Emergency bills are too high: Too often out-of-network providers who provide emergency services -- a circumstance where consumers cannot be choosy about whether the provider is in network -- take advantage of the situation and charge fees well in excess of what Medicare or insurance would pay in network.

In cases looked at by DFS investigators, the average emergency out-of-network bill was $7006. That is 14 times what Medicare would pay. The average out-of-network radiology charge was 33 times what Medicare pays. One neurosurgeon charged $159,000 for an emergency procedure for which Medicare pays $8500.

Insurers are paying less of the cost of out-of-network care: The investigation found that insurers are moving to a system that greatly increases how much it costs consumers when they are treated out-of-network. To determine what they would pay for out-of-network care, most insurers used to use what is known as the usual and customary rate (UCR), which is supposed to be an average of actual bills for a procedure in that region. But now most are using the Medicare rate, which decreases how much insurers pay by as much as half or more in some cases. Insurers make this change hard for consumers to understand, because some are told they are going from 80% of the usual and customary rate to 140% of Medicare, which sounds like an improvement, but is not.

In one case, a patient was approved for a surgery using the usual and customary rate. The insurer said it would pay $31,978 of the $47,685 cost. Before the surgery could be done, the insurer changed to a Medicare Fee Schedule and the insurer would only pay $4,864.62.

Consumers can't comparison shop: Because health plans are now switching between different coverage rates for out of network doctors, consumers are left in an incredibly difficult position when they select plans. They simple can't compare apples to apples when, for example, one plan offers to cover 80 percent of UCR and another offers to cover 140 percent of the Medicare rate.

Another issue found during the investigation: even when consumers have no choice but to seek care out of network, most consumers must pay extra charges. Only consumers in HMOs are protected when they must go out of network.

Based on the findings of DFS's investigation, DFS proposed the following solutions:

Increase disclosure from providers: In non-emergency situations, providers should disclose whether or not all services are in-network before such services are provided and how much they will charge, and insurers should disclose how much they will cover.

Increase disclosure from insurers: Insurers should enable consumers to conduct a meaningful "apples to apples" comparison regarding how much of the cost of out-of-network services will be covered when they are choosing a plan, whether the insurer uses UCR or the Medicare rate.

Prohibit excessive fees: Out-of-network providers should be prohibited from charging excessive fees for emergency services.

Improve network protections: Improve network protections: Network adequacy protections must be improved. Consumers not in HMOs should be given the same network adequacy protections provided to consumers with HMO coverage.

New Yorkers who have questions or complaints concerning their medical bill should go to http://www.dfs.ny.gov/consumer/fileacomplaint.htm [3] or visit www.dfs.ny.gov [4].


Links:
[1] https://www.governor.ny.gov/
[2] http://www.governor.ny.gov/assets/documents/DFS Report.pdf
[3] http://www.dfs.ny.gov/consumer/fileacomplaint.htm
[4] http://www.dfs.ny.gov

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