where modern technology meets cutting edge surgery
Contact Us: (315) 765-8448
where modern technology meets cutting edge surgery
Contact Us: (315) 765-8448
Contact Us: (315) 765-8448
Contact Us: (315) 765-8448
Our mission is to provide you with personalized, high-quality care. We are dedicated to improving and maintaining your health through preventative care and treating chronic diseases.
Omni Ambulatory Surgery Center is a multi-specialty center located in Utica, NY. Established in 2015, the center serves as a model for excellence, accredit
Our mission is to provide you with personalized, high-quality care. We are dedicated to improving and maintaining your health through preventative care and treating chronic diseases.
Omni Ambulatory Surgery Center is a multi-specialty center located in Utica, NY. Established in 2015, the center serves as a model for excellence, accredited by The Joint Commission. Omni ASC is equipped with the most advanced surgical equipment and offers a clean, comfortable, convenient setting for your surgical needs.
The typical same-day surgery is usually performed relatively quickly, is low risk, requires a small incision or no external incision, and has a very short recovery period.
Ambulatory surgery centers, known as ASCs, are modern health care facilities focused on providing same-day surgical care, including diagnostic and preventive procedures.
Minimally invasive procedures are surgeries that are performed using the smallest incisions possible so that the body is able to heal more quickly. These procedures are
Ambulatory surgery centers, known as ASCs, are modern health care facilities focused on providing same-day surgical care, including diagnostic and preventive procedures.
Minimally invasive procedures are surgeries that are performed using the smallest incisions possible so that the body is able to heal more quickly. These procedures are often called "keyhole" or laparoscopic surgeries.
Omni Surgery Center offers broad array of services geared to address today’s most common surgical illnesses and injuries. We know there is no such thing as one-size-fits-all cure, so we never use a one-size-fits-all approach to your treatment.
Our goal is to improve and maintain your overall health and to empower you with an understanding of your condition and wellness plan. Let's get started today on path to your life-long wellness.
Our new, state-of-the-art 20,000-square-foot building features four ambulatory surgery operating rooms.
Ambulatory surgery centers are free-stand
Our goal is to improve and maintain your overall health and to empower you with an understanding of your condition and wellness plan. Let's get started today on path to your life-long wellness.
Our new, state-of-the-art 20,000-square-foot building features four ambulatory surgery operating rooms.
Ambulatory surgery centers are free-standing facilities with operating rooms. These centers perform procedures that allow the patient to recover at home once anesthesia has worn off and the patient is able to care for themselves with minimal assistance.
ASCs have much lower infection rates than hospitals for similar surgeries (around one-tenth of hospital rates).
Four spacious Class C operating rooms
A sixteen bay pre-procedure wing
A twenty four bay post-operative recovery wing
A modern comfortable reception and waiting area
Free Wi-Fi service
State of the art infection control
Highly experienced team members
Excellent customer service.
ASC participates with most insurance providers. You may call our office at (315) 765-8448 for insurance verification.
Omni outpatient surgery center features comfortable waiting rooms with magazines and television. Complimentary refreshments are available for sponsors and/or family members.
Omni outpatient surgery center is accredited by The New York State Department of Health (DOH) and The Accreditation Association for Ambulatory Health Care (AAAHC)
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Please send us a message, or call us for an appointment.
Fax any documents to (315) 765-8464
498 French Road, Utica, New York 13502, United States
PHONE: (315) 765-8448 FAX: (315) 765-8464 EMAIL: info@killpain.com
Monday - Friday: 8:00am - 5:00pm
Because of concerns that there may be a conflict of interest when a physician refers a patient to a health care facility in which the physician has a financial interest, New York State passed a law. The law prohibits physicians, with certain exceptions, from referring patients to a facility in which the physician or any of his/her immediate family members have a financial interest. The referral can be made under one condition: the physician must disclose this financial interest to patients and advise them of alternative places where they may go to obtain these services. The Medicare program also requires an ambulatory surgery center to disclose physician ownership of and financial interests in the facility. These disclosures are intended to help patients make a fully informed decision about their health care.
Omni Ambulatory Surgery Center is owned by physicians. The physician who referred you to the Center or who will be performing your surgery or other services in connection with your surgical procedure may be an owner of the Center. Please discuss this matter with your physician so that you may exercise your right to be treated in another health care facility if desired. Upon your request, your physician will provide names and addresses of alternative providers where you may go to obtain services.
Omni Ambulatory Surgery Center has developed this Statement of Patient Rights and Responsibilities to promote patients’ awareness and understanding of their rights and responsibilities when receiving treatment at the Center. We want to encourage you, as a patient at the Center, to communicate openly with your health care team, participate in your treatment choices and promote your own safety by being well informed and actively involved in your care.
Patient Rights
As a patient at Omni Ambulatory Surgery Center, you have the right to:
1. Understand and use these rights.
2. Receive compassionate, considerate and respectful care in a safe environment.
3. Be informed of the name of the physician responsible for coordinating your care and the names, positions and functions of Center staff involved in your care.
4. Receive information from your physician about your diagnosis, treatment and prognosis in terms you can be reasonably expected to understand.
5. Receive from your physician information necessary for you to give informed consent to any proposed procedure or treatment. This information includes a description of the procedure or treatment, its anticipated risks and benefits, alternatives (if any) to the proposed procedure or treatment, and the risks and benefits of any alternatives.
6. Refuse treatment and be informed of the effects this may have on your health.
7. Privacy consistent with the provision of appropriate medical care to you
8. Confidentiality, in accordance with applicable law, of records and information pertaining to your medical condition and treatment.
9. Participate in the planning of your care and be advised in advance of changes to the plan of care.
10. Review your medical record without charge, obtain a copy of your medical record upon payment of a reasonable fee, and authorize the release of information from your medical record to others. You cannot be denied a copy of your record solely because of your inability to pay.
11. Receive information about the Center’s services, its policies and procedures affecting patient care and conduct, and other pertinent information in connection with your treatment at the Center.
12. Receive instructions for continuing care after discharge from the Center.
13. Refuse to participate in research and receive information necessary for you to decide whether to participate in research.
14. An itemized bill and an explanation of charges, even though they may be covered by insurance, and information in advance of your procedure or treatment about any charges for which you may be responsible.
15. Receive treatment without discrimination as to race, color, religion, sex, national origin, disability, sexual orientation or source of payment.
16. An interpreter to provide communication assistance when needed.
17. Receive emergency medical care if you need it.
18. Change your provider if other qualified providers are available.
19. Complain without fear of reprisal about the care and services provided at the Center, and to have the Center respond to you. You may also recommend changes in Center policies and services.
Complaints and concerns can be expressed in any one of the following ways:
a. Discuss with your physician.
b. Discuss with the Center’s Director at (315) 765-8448 or write to:
Director, Omni Ambulatory Surgery Center
498 French Road
Utica, New York 13502
c. Call the New York State Department of Health complaint hotline (800) 804-5447,
or write to:
New York State Department of Health
Centralized Hospital Intake Program
433 River Street, Suite 303
Troy, New York 12180-2299
d. Call the Medicare Beneficiary Hotline (800) 331-7767, or write to:
IPRO
Medicare Beneficiary Complaint Department
1979 Marcus Avenue, Suite 105
Lake Success, New York 11042
20. Have your authorized representative exercise these rights on your behalf if you are unable to do so.
Patient Responsibilities
You are responsible for:
1. Following the treatment plan prescribed by your physician. This may include instructions of other Center personnel. If you believe you cannot follow through with your treatment plan, you are responsible for telling your doctor. You are responsible for outcomes if you do not follow the treatment plan.
2. Asking questions when you do not understand information or instructions.
3. Providing, to the best of your knowledge, complete and accurate information about your health status and medical history, including medications, over-the-counter products and dietary supplements and allergies and sensitivities.
4. Having a responsible adult to transport you home from the Center and remain with you for 24 hours if required by your physician.
5. Providing a copy of your advance directive (health care proxy, living will, DNR order) if you have one.
6. Providing complete and accurate information concerning your insurance coverage and ability to meet financial obligations, and timely payment of any charges not covered by insurance.
7. Treating all Center staff, other patients and visitors with courtesy and respect, and abiding by all Center policies and procedures.
8. Leaving valuables at home and only bringing necessary items to the Center.
9. Keeping appointments, being on time for appointments and calling in advance if you cannot keep your appointments.
Planning in Advance: Advance Health Care Directives
Advance Directives
Omni Ambulatory Surgery Center supports an individual’s rights to make informed health care decisions, including the right to accept or refuse treatment and the right to formulate advance directives.
Advance directives are legal documents or oral instructions that govern how your health care decisions are made and notify your doctors and others about your wishes in case of a serious medical problem that prevents you from deciding for yourself. Examples of advance directives are a health care proxy, consent to an order not to resuscitate (DNR order) and a living will. If you do not plan ahead, family members or other people close to you may not be allowed to make decisions for you and follow your wishes.
In New York State, appointing someone you can trust to decide about treatment if you become unable to decide for yourself is the best way to protect your treatment wishes and concerns. You have the right to appoint someone by filling out a form called a health care proxy. You may obtain a copy of the proxy form and other information about the health care proxy and advance directives from us or from the New York State Department of Health website at:
http://www.health.state.ny.us/nysdoh/hospital/english3.htm
http://www.health.state.ny.us/professionals/patients/health_care_proxy/index.htm
If you have no one you can appoint as your health care agent or do not want to appoint someone, you can also give specific instructions about treatment in advance. Those instructions can be written and are often referred to as a living will. You should understand that general instructions about refusing treatment, even if written down, may not be effective. Your instructions must clearly and convincingly cover the treatment decisions that must be made, including both the kinds of treatment that you do not want and the medical conditions when you would refuse the treatment. You can also give instructions orally by discussing your treatment wishes with your doctor, family members or others close to you.
Putting things in writing is safer than simply speaking to people, but neither method is as effective as appointing someone to decide for you. It is often hard for people to know in advance what will happen to them or what their medical needs will be in the future. If you choose someone to make decisions for you, that person can talk to your doctor and make decisions that they believe you would have wanted or that are best for you, when needed. If you appoint someone and also leave instructions about treatment in a living will, in the space provided on the proxy form itself or in some other manner, your health care agent can use these instructions as guidance to make the right decision for you
If you have an advance directive, you should notify your physician and bring a copy of it to the Center so that it may be included in your medical record. You may also fill out and sign a health care proxy form at the Center. In either case, you should also discuss your treatment wishes directly with your physician.
PLEASE NOTE: It is the policy of Omni Ambulatory Surgery Center that DNR orders be suspended while you are a patient at the Center. In the unlikely event of a life-threatening emergency, professional staff will initiate resuscitation or other stabilizing measures and transfer you to an acute care hospital for further evaluation, regardless of the contents of any advance directives, existing DNR orders or instructions from a health care agent. At the acute care hospital, further treatment or withdrawal of treatment measures already begun will be ordered in accordance with your wishes or advance directives.
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
We are required by law to protect the privacy of your medical information that may reveal your identity, and to provide you with a copy of this notice, which describes the health information privacy practices of Omni Pain & Precision Medicine Medical Group (“OMNI PAIN & PRECISION MEDICINE”), The Omni Ambulatory Surgery Center, LLC (“Omni ASC”), Omni ASC’s medical staff, and the employees, trainees, students and volunteers of Omni Pain & Precision Medicine and Omni ASC.
OUR COMMITMENT TO YOUR PRIVACY
We are committed to protecting the privacy of your medical information. In conducting our business, we will create records about you and the treatment and services we provide to you. These records are our property. However, we are required by law to:
Maintain the confidentiality of your medical information
Provide you with this notice of our legal duties and privacy practices concerning your medical information
Follow the terms of our notice of privacy practices in effect at the time
This notice provides you with the following important information:
§ How we may use and disclose your medical information
§ Your privacy rights in regard to your medical information
§ Our obligations concerning the use and disclosure of your medical information
WHO WILL FOLLOW THIS NOTICE
In handling your medical information, OMNI PAIN & PRECISION MEDICINE and Omni ASC treat themselves as a clinically integrated care setting. OMNI PAIN & PRECISION MEDICINE and Omni ASC may share your medical information as needed to treat you, to seek payment for services, and to conduct day-to-day operations.
The privacy practices described in this notice will be followed by:
§ Any health care professional who treats you at any of OMNI PAIN & PRECISION MEDICINE’s office locations or Omni ASC;
§ All employees, trainees, students and volunteers at any of OMNI PAIN & PRECISION MEDICINE’s office locations or Omni ASC;
§ All Omni ASC medical staff members; and
§ Any business associates of OMNI PAIN & PRECISION MEDICINE or Omni ASC.
When you receive services at Omni ASC, you may receive certain professional services from physicians on Omni ASC’s medical staff who are independent practitioners and not employees or agents of Omni ASC. These independent practitioners have agreed to abide by the terms of this notice when providing services at Omni ASC. Therefore, this notice applies to all of your medical information that is created or received as a result of being a patient at Omni ASC (or OMNI PAIN & PRECISION MEDICINE). However, this notice does not apply to members of Omni ASC’s medical staff for their medical practice in their private offices if they are not employees of OMNI PAIN & PRECISION MEDICINE. As a result, you will also receive a notice of privacy practices from these independent practitioners with respect to their private offices.
A. HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION
The following categories describe the different ways in which we may use and disclose your medical information. Please note that each particular use or disclosure is not listed below. However, the different ways we are permitted to use and disclose your medical information do fall within one of the categories. Special privacy protections may further restrict how we use or disclose confidential HIV-related information, genetic information, alcohol and substance abuse treatment information or mental health information. Some parts of this general notice may not apply to these types of information.
Treatment. We may use and disclose your medical information to provide, coordinate or manage your health care and related services. This may include communicating with other health care providers regarding your treatment and coordinating and managing your health care with others. For example, we may use and disclose your medical information when you need a prescription, lab work, x-rays or health care services. In addition, we may use and disclose medical information when we refer you to another health care provider.
Payment. We may use and disclose your medical information in order to bill and collect payment for the services and items you receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. This may include reviewing services provided for medical necessity and/or undertaking utilization review activities. We also may use and disclose your medical information to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your medical information to bill you directly for services and items.
Health Care Operations. We may use and disclose your medical information to operate our business. These uses and disclosures include internal administration and planning and various activities that improve the quality and cost effectiveness of the care that we deliver to you. For example, we may use your medical information to evaluate the competence and performance of our staff in caring for you, or to educate our staff on how to improve the care they provide for you. We may also use your medical information to conduct cost-management and business planning activities. In addition, we may share your health information with other health care providers and payors for certain of their business operations if the information is related to a relationship the provider or payor currently has or previously had with you, and if the provider or payor is required by federal law to protect the privacy of your health information.
Sign in Sheets - We may use a sign-in sheet at the registration desk where you will be asked to sign your name. Your name will be called in the waiting room when it is time for your provider to see you.
Incidental Disclosures - While we will take reasonable steps to safeguard the privacy of your medical information, certain disclosures of your medical information may occur during, or as an unavoidable result of, our otherwise permissible uses and disclosures of your health information. For example, during the course of your visit, other patients or staff may see, or overhear discussion of, your medical information.
Business Associate - We may disclose your medical information to contractors, agents and other business associates who need the information in order to assist us in obtaining payment or carrying out our business operations. For example, we may share your medical information with a billing company that helps us to obtain payment from your insurance company. Another example is that we may share your medical information with an accounting firm, law firm or risk management organization that provides professional advice to us about how to improve our health care services and comply with the law. If we do disclose your medical information to a business associate, we will have a written contract to ensure that the business associate also protects the privacy of your medical information.
Appointment and Account Balance Reminders. We may use and disclose your medical information to remind you that you have an appointment or a balance on your account. This may occur by phone, letter, automated telephone system, email, text messaging or other methods.
Treatment Alternatives/Health-Related Benefits and Services. We may use and disclose your medical information to inform you of treatment alternatives and/or health-related benefits and services that may be of interest to you.
Required by Law. We will use or disclose medical information about you when required by federal, state or local law.
Student Immunization Records. We may disclose proof of immunization to schools in states that have school entry or similar laws where such laws prohibit a child from attending school unless the school has proof of immunizations. We are required to obtain agreement from a parent, guardian, person acting for the individual or directly from the individual if he/she is an emancipated minor. Agreement may be oral.
Public Health Activities and Food and Drug Administration. We may disclose your medical information for public health and adverse event or product monitoring activities, including generally to: prevent or control disease, injury or disability; maintain vital records, such as births and deaths; report child abuse or neglect; notify a person regarding potential exposure to a communicable disease; notify a person regarding a potential risk for spreading or contracting a disease or condition; report reactions to drugs or problems with products or devices; notify individuals if a product or device they are using has been recalled; and notify your employer under limited circumstances, related primarily to workplace injury or illness or medical surveillance.
Abuse, Neglect or Domestic Violence. We may disclose your medical information to a government authority if we believe you are a victim of abuse, neglect or domestic violence. If we make such a disclosure, we will inform you of it, unless we think that informing you places you at risk of serious harm or, if we were to inform your personal representative, it is otherwise not in your best interest. We will make every effort to obtain your permission before releasing this information, but in some cases we may be required or authorized to act without your permission.
Health Oversight Activities. We may disclose your medical information to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws, and the health care system in general.
Lawsuits and Administrative Proceedings. Excluding certain conditions, we may disclose your medical information in response to a court order or subpoena if you are involved in a lawsuit or administrative proceeding.
Law Enforcement. We may disclose your health information to law enforcement officials, so long as applicable legal requirements are met, for law enforcement purposes. These purposes include: to comply with court orders or laws; to assist law enforcement officers with identifying or locating a suspect, fugitive, witness or missing person; if you have been the victim of a crime and (1) we have been unable to obtain your agreement because of an emergency or your incapacity, (2) law enforcement officials represent that they need this information immediately to carry out their law enforcement duties, and (3) in our professional judgment disclosure to these officers is in your best interests; if we suspect that your death resulted from criminal conduct; if necessary to report a crime that occurred on our property; or if necessary to report a crime discovered during an offsite medical emergency.
Coroners, Medical Examiners, and Funeral Directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. We may also release medical information about patients to funeral directors as necessary to carry out their duties.
Organ and Tissue Donation. We may disclose your medical information to organizations that handle organ and tissue procurement, banking or transplantation.
Research. In most cases, we will ask for your written authorization before using your health information or sharing it with others in order to conduct research. However, under some circumstances, we may use and disclose your health information without your written authorization. To do this, we are required to obtain approval through a special process to ensure that research without your written authorization poses minimal risk to your privacy. Under no circumstances, however, would we allow researchers to use your name or identity publicly. We may also release your health information without your written authorization to people who are preparing a future research project, so long as any information identifying you does not leave our facility. In the unfortunate event of your death, we may share your health information with people who are conducting research using the information of deceased persons, as long as they agree not to remove from our facility any information that identifies you.
Serious Threats to Health or Safety. We may use and disclose your medical information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to someone able to help prevent the threat, for example, to law enforcement officers if you participated in a violent crime that might have caused serious physical harm to another person.
Specialized Government Functions. We may disclose your medical information if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate military command authorities. In addition, we may disclose your medical information to federal officials for intelligence and national security activities authorized by law. We also may disclose your medical information to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
Inmates and Correctional Institutions. If you are an inmate or under the custody of law enforcement officials, we may disclose your medical information to the correctional institution or law enforcement officials if necessary: (i) to provide you with health care, (ii) for the safety and security of the institution, and/or (iii) to protect your health and safety or the health and safety of other individuals.
Workers’ Compensation. We may release your medical information for workers’ compensation and similar programs.
Completely De-Identified or Partially De-Identified Information. We may use and disclose your medical information if we have removed any information that has the potential to identify you so that the medical information is “completely de-identified.” We also may use and disclose “partially de-identified” medical information about you if the person who will receive the information signs an agreement to protect the privacy of the information as required by federal and state law. Partially de-identified medical information will not contain any information that would directly identify you (such as your name, street address, social security number, phone number, fax number, electronic mail address, website address or license number).
Fundraising Activities. We may contact you to provide information about OMNI PAIN & PRECISION MEDICINE or the Omni ASC sponsored activities, including fundraising programs and events. We would only use contact information, such as your name, address and phone number and the dates you received treatment or services at OMNI PAIN & PRECISION MEDICINE or the Omni ASC. If we contact you in this regard, we will give you the opportunity to opt out from receipt of future fundraising notices, as well as explanation of how to opt out.
Data Breach Notification Purposes. We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.
Deceased Persons. We may disclose PHI to family members or others involved in a decedent's healthcare or payment for care when the disclosure is relevant to their involvement and not inconsistent with the decedent's previously expressed wishes. Also, health information of persons deceased for more than 50 years is not considered PHI and therefore is not regulated under HIPAA.
B. Other limitations
The following uses and disclosures of your Protected Health Information will be made only with your written authorization:
1. Uses and disclosures of Protected Health Information for marketing purposes, where the authorization clearly discloses that we will receive payment; and
2. Disclosures that constitute a sale of your Protected Health Information, whether by direct or indirect remuneration, unless one of several exceptions applies. In addition to sales, this includes PHI access and licensing agreements. The written authorization must disclose that the exchange will result in remuneration.
Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose Protected Health Information under the authorization. But disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation.
In accordance with state law, we will further limit the disclosures to third parties of protected confidential HIV-related information and information concerning genetic testing, mental health services and certain alcohol and substance abuse treatment.
C. YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION
You have the following rights regarding the medical information we maintain about you:
Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your medical information for treatment, payment or health care operations. Additionally, you have the right to request that we limit our disclosure of your medical information to individuals involved in your care or the payment for your care, such as family members and friends.
We are not required to agree to your request to restrict or limit our use of disclosure of your medical information. If we agree to your request, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat to you.
Unless the disclosure is required by law, we will abide by your request to restrict disclosures of your health information to health plans for payment or operations purposes where the health information pertains solely to a health care item or service for which you, or someone on your behalf, paid us out of pocket in full. .
Inspection and Copies. You have the right to inspect and obtain a paper or electronic copy of the health information we retain that may be used to make decisions about you, including medical and billing records, but not including psychotherapy notes.
Right to a Paper Copy of This Notice. You have a right to receive a paper copy of our notice of privacy practices at any time.
Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us or with the Office of Civil Rights of the U.S. Department of Health and Human Services.
Right to Provide an Authorization for Other Uses and Disclosures. We will obtain your written authorization for uses and disclosures that are not identified by this notice or are not permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your medical information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your medical information for the reasons described in the authorization. Of course, we are unable to take back any disclosures that we have already made with your authorization. We are required to retain records of the care that we provided to you.
Right to Be Notified of a Breach. You have the right to be notified upon a breach of unsecured Protected Health Information in the event you are affected by such breach.
Your Rights and Protections Against Surprise Medical Bills
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:
o Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
o Cover emergency services by out-of-network providers.
o 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.
o Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.
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.
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