Finding yourself with an unexpected medical bill can be stressful. Understanding your rights and protections, especially regarding balance billing, is crucial. This article provides essential information about surprise medical bills and how to navigate them, particularly for Healthfirst members seeking the Healthfirst Customer Service Number.
Understanding Balance Billing and Your Rights
Balance billing, often called “surprise billing,” occurs when you receive a bill from an out-of-network provider for the difference between what your insurance pays and the provider’s total charge. This can happen even if you receive care at an in-network facility. Fortunately, you have protections against balance billing in certain situations.
Emergency Services
If you receive emergency care from an out-of-network provider or hospital, you are protected from balance billing. You are only responsible for your in-network cost-sharing, such as copayments, coinsurance, and deductibles. This protection extends to services received after your condition stabilizes.
Specific Services at In-Network Facilities
Certain out-of-network providers at in-network hospitals and ambulatory surgical centers cannot balance bill you. This includes services like:
- Emergency medicine
- Anesthesia
- Pathology
- Radiology
- Laboratory services
- Neonatology
- Assistant surgeon services
- Hospitalist services
- Intensivist services
These providers are prohibited from balance billing you and cannot request you waive your protection against it. For other services at these facilities, out-of-network providers cannot balance bill you unless you provide written consent, knowingly waiving your protections. You cannot waive this protection for surprise bills. Surprise bills arise when a participating doctor was unavailable, an unknown non-participating doctor provided services, or unforeseen medical services were necessary.
Referrals from In-Network Doctors
If your in-network doctor refers you to an out-of-network provider without your consent, including for lab or pathology services, you are protected from balance billing. These providers cannot request that you waive your protections. To ensure full protection, you might need to sign a specific form available on the Department of Financial Services website.
Your Responsibilities and Health Plan Obligations
You are not obligated to waive your protection from balance billing or seek out-of-network care. Choosing in-network providers and facilities is always an option. When balance billing is prohibited:
- You only pay your in-network cost-sharing.
- Your health plan pays the remaining balance to the provider directly.
- Your health plan typically covers emergency services without prior authorization.
- Your cost-sharing is based on in-network rates.
- Payments for emergency or out-of-network services count towards your in-network deductible and out-of-pocket maximum.
Resolving Billing Disputes
If you believe you have been wrongly billed, contact the New York State Department of Financial Services (NYSDFS). They can provide assistance and information regarding your rights. While this article provides valuable information, contacting Healthfirst customer service directly or the NYSDFS is recommended for specific guidance. You can visit the NYSDFS website for more details. Remember, knowing your rights empowers you to navigate unexpected medical expenses effectively.
