Surprise Bills for Health Care Services
MetroPlus will only cover services provided by out-of-network providers for emergency services and when prior authorization is obtained and we have approved a specific out-of-network provider. If you believe your patient needs to obtain services from an out-of-network provider, please contact MetroPlus before referring the patient.
What you need to know about Surprise Bills
If you are a health care provider
If your patient has coverage through an HMO or insurer subject to NY law (coverage that is not self-insured):
- Hospital and Ambulatory Surgical Center. A bill will be a surprise bill if your patient receives services from a non-participating doctor at a participating hospital or ambulatory surgical center and:
- A participating doctor was not available; or
- A non-participating doctor provided services without your patient's knowledge; or
- Unforeseen medical circumstances arose at the time the health care services were provided.
- A bill will also be a surprise bill if your patient is referred by a participating doctor to a non-participating provider and your patient did not sign a written consent acknowledging that the services would be out-of-network and would result in costs not covered by the patient's health plan.
- Assignment of Benefits Form. When your patient signs an assignment of benefits form for a surprise bill, your patient will only be responsible to pay you the in-network cost-sharing. You can’t bill the patient for any amounts in excess of your patient's in-network cost-sharing.
- When You Bill A Patient. If you are a doctor and are billing a patient for what could be a surprise bill, you are required to include an assignment of benefits form and a claim form for a third party payer with the patient's bill.
Management of Chronic Conditions
Chronic conditions affect patients in every age group. Unmanaged, or poorly managed, chronic conditions often lead to serious complications for patients and their families. Regardless of the condition, chronic conditions present challenges for patients, including:
- Dealing with symptoms
- Complex medication regimes
- Difficult lifestyle adjustments
- Access needed care and services
Tips for Providers:
- Deliver care based on recognized clinical guidelines. Clinical Practice Guidelines help by providing evidence-based recommendations for the evaluation and treatment of select common conditions. The MetroPlus Clinical Practice Guidelines are updated regularly, and can be found on the provider portal.
- Consider the goals of patients/caregivers and promote realistic and specific self-management activities.
- Provide personalized culturally sensitive care (cookie cutter approaches do not work). Managing chronic conditions will require patient/caregiver buy-in.
- Develop a plan of care that includes teaching patients/caregivers early warning signs and what actions to take (i.e. when to call you, when to go to an urgent center verses the emergency room).
- Provide coordinated care, including all members of the health care team (nursing staff, care managers, specialist, pharmacist).
- Please visit our provider portal for additional information regarding clinical practice guidelines.