Health Plan To Stop Improper Patient Billing Notices

Attorney General Spitzer today announced a settlement that will require a leading health plan in New York to stop sending misleading notices to its policyholders and provide restitution to consumers who were overcharged by ambulance providers.

Under the agreement, Empire BlueCross BlueShield (Empire) will stop sending notices that misstate that some of its policyholders must pay the difference between the amount the out-of-network ambulance provider charged and the amount Empire paid. The agreement allows consumers to seek restitution if, as a result of Empire’s misleading notices, they were improperly charged by ambulance providers for services that, by law, Empire should have covered.

The settlement is the latest in the Attorney General’s ongoing statewide "Project Clean Bills of Health" initiative to eliminate improper medical billing.

"Consumers should not face improper bills for crucial ambulance services," said Spitzer. "Health plan notices and bills to ambulance patients and providers need to clearly and accurately state patient liability under the law."

The Attorney General’s Health Care Bureau investigated Empire after receiving a complaint about the health plan’s notices, called "explanations of benefits." Empire sent the notices to ambulance providers who were not in the health plan’s network of participating ambulance services, as well as to patients who received ambulance services from these out-of-network providers. The notices erroneously told consumers that, "[s]ince you have received care from an out-of-network [ambulance] provider, the provider is entitled to bill you for the amount shown [below]." The amount on bill notices that consumers received was the difference between the ambulance provider’s charge and the amount Empire paid.

Such "balance billing" is prohibited under New York’s "Ambulance Mandate," which went into effect on January 1, 2002. The Ambulance Mandate requires most health plans - - including Empire - - to pay bills for emergency out-of-network ambulance services at a reasonable rate, and prohibits the ambulance provider from billing the consumer for the difference between the amount the health plan paid and the amount the ambulance provider billed. The ambulance provider, however, may collect any copayment, coinsurance, or deductible for which the consumer is responsible under his or her health plan.

Under the agreement, Empire will send thousands of corrected notices to its members who used ambulance services and received the erroneous notices. If consumers were billed by the ambulance provider, they can contact Empire, which will in turn contact the ambulance provider on the consumer’s behalf to request that the provider refund the amount improperly collected from the consumer. If the ambulance provider does not respond or refund the improperly collected money to the consumer, Empire will refund the money to the consumer as long as the consumer authorizes Empire to collect the money from the provider.

Spitzer commended Empire, which recently merged with WellPoint, Inc., for cooperating with his office to promptly resolve this matter.

A statewide investigation of potentially improper billing and reimbursement practices for ambulance service is continuing.

This matter was handled by Troy Oechsner, Health Care Deputy Bureau Chief, under the supervision of Health Care Bureau Chief Joseph Baker.

Consumers with questions or concerns about ambulance billing or health care matters may call the Attorney General’s Health Care Bureau at 1-800-771-7755 (Option 3) or visithttp://www.ag.ny.gov/bureaus/health_care/about.html

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