Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

 

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health  plan to provide services. Out-of-network providers may be allowed to bill you for the difference  between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

 

You’re protected from balance billing for:

Emergency services

If you have an emergency medical condition and get emergency services from an out-of-network provider or hospital, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in a stable condition, unless you give written consent and give up your protections not to be balanced billed for these  post-stabilization services.  If your insurance ID card says “fully insured coverage,” you can’t give written consent and give up your protections not to be balance billed for post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. If your insurance ID card says “fully insured coverage,” you can’t give up your protections for these other services if they are a surprise bill. Surprise bills are when you’re at an in-network hospital or ambulatory surgical facility and a participating doctor was not available, a non-participating doctor provided services without your knowledge, or unforeseen medical services were provided. 

Services referred by your in-network doctor

If your insurance ID card says “fully insured coverage,” surprise bills include when your in-network doctor refers you to an out-of-network provider without your consent (including lab and pathology services). These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. You may need to sign a form (available on the Department of Financial Services’ website) for the full balance billing protection to apply.   

 

You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network.

 

When balance billing isn’t allowed, you also have these protections:

  • You’re only responsible for paying your share of the cost (like the copayments, coinsurance,   and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
  • Generally, your health plan must:
    • Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
    • Cover emergency services by out-of-network providers.
    • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
    • Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

Auburn Community Hospital is dedicated to the patients we serve. If you believe you have received a bill in error please contact our billing department at (315) 255-7210 to review your balance with one of our dedicated team members.

If you think you’ve been wrongly billed and your coverage is subject to New York law (“fully insured coverage”), contact the New York State Department of Financial Services at (800) 342-3736 or surprisemedicalbills@dfs.ny.gov. Visit http://www.dfs.ny.gov for information about your rights under state law.

Contact CMS at 1-800-985-3059 for self-funded coverage or coverage bought outside New York. Visit http://www.cms.gov/nosurprises/consumers for information about your rights under federal law.

 

Physician Services

Physician services provided in the hospital are not included in the hospital charges. Physicians who provide services in the hospital may or may not participate with the same plans as the hospital. Patients should check with the physician arranging for the hospital services to determine the plans in which the physician participates.

For questions regarding physician billing outside of Auburn Community Hospital please contact the following providers:

Organization Address Phone
AMMS 17 Lansing St
Auburn, NY 13021
315.255.7576
Anesthesia Services Medical Management Resources Inc (MMRI)
5000 Brittonfield Pkwy #500
East Syracuse, NY 13057
315.446.0033
Associated Medical Professions 192 Genesee St
Auburn, NY 13021
315.258.5253
Auburn Cardiology Associates 281 Grant Avenue
Auburn, NY 13021 
315.253.4456
Auburn Community Hospitalists 101 1st Avenue NE
Suite 150
Cullman, AL 35055
256.208.3000
Auburn Ophthalmology 144 Genesee Street
Suite 502
Auburn, NY 13021
315.253.3217
CNY Orthopedic Sports Medicine 2200 East Genesee Street
Syracuse, NY 13210
315.422.9233
Eastern Finger Lakes EMC (Emergency Care) Med Care Administrators
9360 River Rd
Marcy, NY 13403
315.736.2080
Hematology-Oncology Associates of CNY 37 West Garden Street
Suite 301
Auburn, NY 13021
315.472.7504
LabCorp 69 First Ave.
Raritan, NJ 08869
1-800-524-0249
Nephrology Hypertension Associates of CNY 6846 Buckley Road
North Syracuse, NY 13212
315.410.6400
Paragon Practice Solutions (Pathology) 6390 Fly Road
East Syracuse, NY 13057
315.216.5021
Sleep Center at Auburn Community Hospital 17 Lansing St
Auburn, NY 13021
315.255.7730
Specialty Care Neruo-Monitoring 3 Maryland Farms
Suite 200
Brentwood, TN 37027
615.346.8736
Upstate Hematology/Oncology 750 East Adams Street
Syracuse, NY 13210
315.464.5290
Upstate ICU-CCU and Pulmonary 17 Lansing St
Auburn, NY 13021
315.255.7011
Upstate Orthopedics 6620 Fly Road
Suite 200
East Syracuse, NY 13057
315.464.4472
Upstate Urology 750 East Adams Street
Syracuse, NY 13210
315.464.1500
UR Imaging Sciences Collection and Billing
175 Corporate Woods
Suite 100
Rochester, NY 14623
585.758.7801
URMC Neurology
601 Elmwood Avenue
Rochester, NY 14246
585.275.1200
Victory Sports Medicine 791 West Genesee Street
Skaneateles, NY 13152
315.685.7544