Attorney Mark Scherzer Discusses Surprise Bill at New York State Health Foundation

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Mark P. Scherzer

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  • Serving New York, NY

  • Credit cards accepted, Fixed hourly rates, Fixed fees available

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Serving New York, NY

Credit cards accepted, Fixed hourly rates, Fixed fees available

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Mark Scherzer shared the podium with Troy Oechsner, the Deputy Superintendent of Health at the State Department of Financial Services, at a luncheon forum at the New York State Health Foundation on on June 28, 2016:  "New York’s Emergency Medical Services and Surprise Bills Law: A Conversation with an Advocate and an Enforcer"

Mark outlined the eight year
history of consumer advocacy that led to the adoption of the
law in 2014, and has since become a model for laws in other
states.  What started with efforts in the last decade to make
sure that health plans fairly computed the amounts they paid
for out of network medical services and to require all
network-base health plans to pay for out of network specialty
care when there were no adequate specialists in the network
for an individual’s medical problem evolved over time. The
Surprise Bill law included nut just a right to go out of
network when necessary,but also a right to an independent
decision about whether going out of network is medically
necessary.  It requires that all plans  have adequate networks
to serve their members’,medical needs.

As described in Mark’s guest blog for Families USA, the
law also requires current and accurate disclosure to members
of how plans reimburse,of  how physicians and hospitals charge
for their services, and  of what networks hospitals, doctors
and other providers participate in. When consumers receive
"surprise bills", in which they did not get prior notice of
the necessary facts, or had no choice, or no network doctors
were available, they can assign their benefits to their doctor
and force the doctor and the health plan to negotiate a fee,
while they pay only their network co-payment.

Mark identified gaps in the law, which does not cover situations where the consumers are not required to get referrals (such as visits to primary care physicians who are incorrectly represented to be in the network). Consumers who live and get medical care in New York, but who have coverage through plans issued to employers in other states, also may have very limited rights, as do consumers in self insured plans and Medicare Advantage plans.  Mark urged the New York State Health Foundation to fund studies of the effects of the law on consumers and to point to areas where it might be improved. 

Mark Scherzer is a New York health, life, and disability insurance
lawyer who represents claimants and individual policy-holders with claims
arising under employer-sponsored group ERISA benefit plans (such as short and long term disability benefits) and under individual insurance policies.

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