No Surprise Act
Research shows many consumers are confused about how health care costs work and often have concerns regarding their out-of-pocket costs. At South Shore Surgery Center, we’re here to provide clarity and help you understand what to expect regarding your cost of care and any potential financial responsibility you may have.
If you have health insurance, it’s important to understand the details of your specific plan, as well as how physicians (surgeon and anesthesiologist) and free-standing ambulatory surgery center charges work. If you do not have health insurance, please make your physician aware.
Call South Shore Surgery Center at 631.293.9700 for estimated costs for services provided at South Shore Surgery Center
Please check with your health plan to confirm your physicians’ insurance participation.
Understanding your insurance
Since any out-of-pocket costs are determined by the details outlined by your insurance plan product, it’s important to understand the specifics – including what’s in-network and what you may be financially responsible for.
South Shore Surgery Center is a participating provider in many health plan networks. Some plans use smaller networks for certain products they offer, so it’s important to check whether or not we participate in the specific plan you are covered by. See if your insurance is accepted.
Avoiding surprise balance bills
If South Shore Surgery Center and/or the treating provider does not contract with your specific health plan, South Shore Surgery Center and/or providers will be considered “out-of-network” (“OON”). Receiving services from an OON provider will result in additional out-of-pocket costs to patients. Patients will be responsible for these costs including any copay, coinsurance, deductible and the difference between the charges billed to and paid by the health plan. This balance is commonly referred to as a “balance bill”. South Shore Surgery Center will happily provide patients with a “good faith estimate” of costs for services in advance so that there are no surprise balance bills. If a patient is not aware and does not consent to services from an OON physician, hospital or facility prior to the services being provided, this is considered a “surprise bill” or a “surprise balance bill”.
Patient protections against surprise balance bills
- Patient responsibility to pay for OON providers providing ancillary services at a free-standing ambulatory surgery center is limited to in-network cost sharing unless notice and patient consent is given prior to the service. These ancillary services may include services related to anesthesia, pathology, laboratory and services provided by assistant surgeons.
- Patient responsibility for OON providers providing non-emergency services is limited to cost sharing that would be applicable for such in-network non-emergency services unless patient is provided prior notice and consents to having services provided by an OON provider.
- Even if care is provided at an in-network free-standing ambulatory surgery center, the providers who work at that free-standing ambulatory surgery center are not included in the free-standing ambulatory surgery center fees and will bill separately. These providers may or may not participate with the health plan. Ask your provider what type of other providers might provide care while you are in the free-standing ambulatory surgery center.
- You are never required to get OON care. You can choose a provider in your health plan’s network.
Good faith cost estimates are available to protect patients against surprise bills
You have the right to receive a good faith estimate for the total expected cost of any non-emergency items or services. This includes related costs such as medical tests, prescription drugs, equipment and free-standing ambulatory surgery center fees. One way to prevent surprise and/or balance bills is to get a good faith estimate for your care. To get a good faith estimate please call 631.293.9700.
You have the right to receive a good faith estimate outlining how much your medical care is expected to cost. Health care providers are required to give patients who don’t have insurance, or who are not using insurance, a cost estimate for medical items and services. Make sure you receive a good faith estimate in writing at least one (1) business day before your anticipated medical service or item. You can also request a good faith estimate before scheduling an item or service. If you receive a bill that is $400 or more than your good faith estimate, you can dispute the bill. Make sure to save a copy or picture of your good faith estimate.
The physician services you receive in the free-standing ambulatory surgery center are not included in the free-standing ambulatory surgery center’s charges. Physicians bill for their services separately and may not participate in the same health plans as the free-standing ambulatory surgery center, so always check which plans your doctor participates in.
What to ask your doctor(s) before you schedule non-emergency medical care:
- Does the doctor participate in your health insurance plan product?
- Does the free-standing ambulatory surgery center participate in your health insurance plan product?
- Does the anesthesiologist at the free-standing ambulatory surgery center participate in your health insurance product?
- Will there be other doctors or providers involved in your care?
– If so, what is the name and contact information for each of the other doctors involved in your care?
You’ll need to contact each to find out if they participate in your health insurance plan. If the doctor does not participate, ask for an estimated cost for the services that will be billed.
What is a surprise bill?
If you receive health care from an in-network doctor or free-standing ambulatory surgery center, you may unknowingly receive care from an out-of-network provider during that time and incur unanticipated expenses—called a surprise bill. Usually, the out-of-network provider sends a bill to your insurance company, which pays a portion of the bill. The remainder of the bill is then sent to you. To ensure a provider is in-network, check directly with your health insurance carrier.
It is not a surprise bill if you chose to receive services from an out-of-network doctor instead of an available in-network doctor. You may have signed a written consent that you knew the services would be out-of-network, possibly resulting in costs not covered by your health insurance plan.
Both federal and New York State laws protect patients from surprise bills, meaning bills for health care services, that are performed by an out-of-network provider without the patient’s prior knowledge or approval. This law requires physicians and free-standing ambulatory surgery centers to notify you about the health plans in which they participate and share the names and contact information for all providers who will be involved in your care, including those who are out-of-network. Providers must disclose health plan participation prior to rendering non-emergent services. Patients are also entitled to a good faith estimate.
Hold harmless protections for insured patients
Your health insurance plan must protect you from surprise bills for OON non-emergency services in a free-standing ambulatory surgery center which are covered by your health insurance plan—this is called a hold harmless protection. You do not have to pay out-of-network provider charges for non-emergency services in a surprise bill, which are covered by your health insurance plan, that are more than your in-network copayment, coinsurance or deductible. Let your insurance company know if you receive a surprise bill from an out-of-network provider for non-emergency services.
Uninsured patients or patients with employer or union self-insured coverage
You may be able to file a dispute through the independent dispute resolution process if you do not have HMO or insurance coverage that is subject to New York state law (e.g., if you are uninsured or your employer or union self-insures) and you receive a bill from a doctor for non-emergency services that you believe is excessive.
What to do if you receive a surprise bill
You can dispute a surprise medical bill.
Patients with insurance (coverage with HMO or insurer subject to New York state law, or coverage that is not self-insured): You will be protected from a surprise bill and will be responsible only for an in-network copayment, coinsurance or deductible if you do both of the following:
- Sign an assignment of benefits form to permit the free-standing ambulatory surgery center and/or provider to seek payment for the bill from your health insurance plan.
- Send the form to your health insurance plan and your provider or the applicable free-standing ambulatory surgery center, and include a copy of the bill or bills you do not think you should pay. You can contact your insurance company directly for information related to where these types of forms and supporting documentation should be sent.
Uninsured patients or patients with employer or union self-insured coverage, or insured patients who do not assign benefits for surprise bills—If you are uninsured or your employer or union self-insures, you may dispute a surprise bill by using the New York state independent dispute resolution (IDR) process. To submit a dispute, you must complete the IDR patient application and send it to:
NYS Department of Financial Services
Consumer Assistance Unit/IDR Process
One Commerce Plaza
Albany, NY 12257
This process includes several components, including an independent dispute resolution entity (IDRE) that reviews the dispute. Decisions will be made by a reviewer with training and experience in health care billing, reimbursement, and usual and customary charges, in consultation with a licensed doctor in active practice in the same or a similar specialty as the doctor providing the service that is the subject of the dispute. The IDRE will make a determination within 30 days of receipt of the dispute.
For more information, visit the Department of Financial Services.
Questions about submitting a dispute
Contact the New York State Department of Financial Services at (800) 342-3736 or email IDRquestions@dfs.ny.gov if you have questions or need help.
Through our financial assistance program, we provide discounted services based on financial need to those who are uninsured, underinsured, ineligible for government programs or other third-party coverage, or otherwise unable to pay for medically necessary care. For more information call 631.887.0890.