This week, Crain’s Health Pulse highlighted a lawsuit that I and my colleagues Dan Hallak and Jack Martins commenced earlier this week. We filed the lawsuit on behalf of 18 physician practices and four Empire Plan enrollees in the Supreme Court, Albany County, contending that the New York State Health Insurance program has attempted to sidestep the state’s surprise-billing law, drastically reducing payments for out-of-network services more than 80 percent.

The federal No Surprises Act (NSA) took effect on January 1, 2022 – governing how managed care companies reimburse out-of-network providers and how disputes between health plans and out-of-network providers are resolved. This law is designed to manage patients’ costs for emergency services or health care they receive at an in-network facility, from out-of-network doctors. Federal and state laws have established different benchmarks for determining a “reasonable amount” when insurers and physicians disagree. In this case, the health plan has opted to funnel these surprise-billing disputes through the federal government’s adjudication system, instead of the process outlined in New York state’s surprise billing law.

This lawsuit underscores the importance of understanding key issues. How does the NSA work within the existing New York Surprise Bill Law, and what is the impact on health practices that are chiefly out-of-network, such as anesthesiology, pathology and surgical care? How can practices best serve patients while protecting their business?