Michael J.

Fara

139 Livingston Avenue

Yonkers, New York 10705-2224
(914) 318-0637
llijfAIIA@IJIIIAiLAAIII

December 22, 2015

Joanette I. Claridge-Weisse
Department of Emergency Medicine
St. John's Riverside Hospital Dobbs Ferry Pavilion
128 Ashford Avenue
Dobbs Ferry, NY 10522

Dear Doctor Weisse:

I was a emergency room patient of yours on September 6, 2015. I came in for a damaged leg. On
December 21, I received a letter dated December 11, 2015 for a bill in the amount of $243.00. I have
contacted your billing department multiple times, and so has my insurance company, today, to resolve an
issue with this surprise charge regarding my emergency room visit at St. John's Riverside Hospital at
Dobbs Ferry, NY on September 6, 2015. First, please be advised that my insurance company has
escalated this case, and that even after offering to pay your billing department the balance that was sent to
me:

They have refused to accept the payment my insurance company has sent me in the amount of
$61.58 and have refused an Explanation of Benefits report from both myself and my insurance
company.
They have refused, according to my insurance company, to accept a payment from my insurance
company, because it was out-of-network, even though my insurance company is now escalating
the claim because it was an emergency, and is WILLING to pay you.
At no time, in the emergency room, was I made aware that you were out of network.
According to NYS Department of Health, under New York State Public Health Law (PHL) 24,
effective March 31, 2015, you were required to notify me of out-of-network costs, or I am only
liable for a standard co-pay.

I would like to reiterate to you that I have tried to explain these facts to your billing department, only to
be yelled at, told they don't make outgoing calls when asking them to call back my insurance company, et
al. I consider such a situation entirely unprofessional and regrettable and hope that your office will be
willing to resolve this billing issue with me directly.
Sincerely,

Michael Fara

WYORK
TE OF

ORTUNITY.

ANDREW M. CUOMO
Governor

Department
of Health
HOWARD A. ZUCKER, M.D., J.D.

SALLV DRESLIN, M.S., R.N.

Acting Commissioner

Executive Deputy Commissioner

March 16, 2015

Re: Revised Effective Date

Dear Doctor:
As you may be aware, New York State Public Health Law (PHL) 24, effective March 31,
2015, requires physicians and other health care professionals to make certain disclosures to
patients and prospective patients regarding out-of-network providers. The intent of this law is to
enable health-care consumers to make informed decisions regarding their use of providers, and
to avoid receiving "surprise bills" from providers who are not participants in patients' health
insurance plans. It is important for physicians and other health care professionals to comply
with the patient disclosure requirements of PHL 24. Willful or grossly negligent failure to do so
may be considered misconduct, as defined in New York State Education Law (SED) 6530.
Also note, physicians have rights for bringing disputes for payment of bills for emergency
services and surprise bills to independent dispute resolution under New York Financial Services
Law (FSL) Article 6. Under FSL 606, if a patient assigns benefits for a surprise bill to a nonparticipating physician, the non-participating physician must not bill the patient except for any
applicable copayment, coinsurance or deductible that would be owed if the patient used a
participating physician. Willful or grossly negligent failure to comply with this requirement may
also be considered misconduct, as defined in SED 6530.
Please familiarize yourself with the provisions of PHL 24, as well as FSL 606, in order
to facilitate your compliance with said statutes. For your convenience, the enclosed summary
provides the highlights of the laws. We expect further information to be posted shortly at
www.dfs.ny.gov. You may also wish to consult with your state medical or osteopathic society,
specialty society, local county society, an attorney, or other source for further guidance on
ensuring your practice is complaint with PHL 24 and FSL 606.
Thank you for your anticipated cooperation and compliance with these requirements. If
you have any questions or concerns, you may contact me at (518) 402-0855.

Sincerely,

Keith W. Servis
Director
Office of Professional Medical Conduct

Empire State Plaza, Corning Tower, Albany, NY 12237 health.ny.gov

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THIS IS NOT A BILL

CHECK NUM!ll;IR:

YOUR BENEFIT SNAPSHOT'

0042699770

BENEFIT
AMOUNT
PATIENT:
PATIENT AC:IDUNT #:
I NSURED I C.:
PROVIDER:
CLAIM#:
PROVIDER F-IRTICIPATION STATUS
CLAIM RECEII.IED DATE:
EOB DATE:
AMOUNT PRC>! DER MAY Bl LL YOU,
I F NOT AL~Y PAID

FARA. MICHAEL J
05062375DFE081124
907A78942
CLARIDGE-WEISSE, J
2015259CK7126
OUT OF NETWORK
09/16/2015
09/22/2015

BENEFIT YEAR 2015

INDIVIDUAL IN-NETWORK OUT-OF-POCKET-LIMIT
FAMILY-IN-NETWORK OUT-OF-POCKET-LIMIT

AMOUNT METYEAR TO DATE

2,000. 00
4,000. 00

230. 00
230. 00

REMAINING
BALANCE
1,770. 00
3, 770. DO

SI neceslta ayuda en espal'lol

para entender este documento,
puede sollcltarla sin costo
adlclonal, llamando al numero
de servlclo al cllente que
aparece al dorso de su tarjeta
de ldentlftcacl6n o en el folleto
de lnscrlpcl6n.

o. oo
Medical Necessity reviews for your health benefit plan are performed under the Anthem UM Services,
Inc. license.

FARA, MICHAE.. J

139 LIVINGSTOl'J AVE

DATE(\) OF
SER"I\ICE

CODES

09/06/2015-19/06/2015

99283

TYPE OF
SERVICE

EMERGENCY SERVICE

TOilLS

YONKERS
CHARGE

NY 10705
ALLOWABLE
AMOUNT

PROVIDER
~ESPONSIBILIH

243. DO

62. 8!

180. 12

243. 00

62. 88

180. 12

REASON
CODE(S)

DEDUCTIBLE

45

YOU CAIi LEARN MORE ABOUT THE SERVICES LISTED BY CALLING THE CUSTOMER SERVICE PHONE NUMBER ON THE
BACK
YOUR ID CARD. WE CAN TELL YOU THE DIAGNOSIS AND TREATMENT CODES INCLUDED ON YOUR CLAIM,
ALONG ._ITH THE DESCRIPTIONS FOR THOSE CODES.

ANSI C.OES
000251 N 45

EXPLANATION
CHARGE EXCEEDS FEE SCHEDULE/MAXIMUM ALLOWABLE OR CONTRACTED/LEGISLATED FEE ARRANGEMENT.

ADDITIONAL
COPAY/
MEMBER
COINSURANCE RESPONSIBILITY

REASON
CODE(S)

AMOUNT
PAID TO
MEMBER

0.00

0. 00 I
0. 00

0. 00

62. 88

0.00

0.00

0.00

62. BB

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THIS IS NOT A BILL

CHECK NUMBER :

YOUR BENEFIT SNAPSHOT'

NA

PATIENT:
PATIENT ACCOUNT#:
I NSURED I ():
PROVIDER:
CLAIM #:
PROVIDER P'ARTICIPATION STATUS
CLAIM RECEIVED DATE:
EOB DATE:
AMOUNT PROVIDER MAY Bl LL YOU,
I F NOT AL~EAOY PAI D

BENEFIT
AMOUNT

BENEFIT YEAR 2015

INDIVIDUAL IN-NETWORK OUT-OF-POCKET-LIMIT
FAMILY-IN-NETWORK OUT-OF-POCKET-LIMIT

FARA,MICHAEL J
05062375DFE100442
907A7B942
CLARIDGE-WEISSE, J
2015352BK2882
OUT OF NElWORK
12/18/2015
12/22/2015

AMOUNT METYEAR TO DATE

2,000. 00
4, 000. 00

328. 78
328. 78

REMAINING
BALANCE
1,671 . 22
3, 671 . 22

SI neceslta ayuda en espal'lol

para entender este documento,
puede solicltarla sin costo
adlclonal, llamando al numero
de servlclo al cllente que
aparece al dorso de su tarjeta
de ldentlflcaclon o en el folleto
de lnscrlpclon.

0.00
Medical Necessity reviews for your health benefit plan are performed under the Anthem UM Services,
Inc. license.

FARA, Ml CHAil J

139 LIVINGSTON AVE

DATE(S) OF
SER~CE

CODES

09/06/2015-09/06/2015

99283

TYPE OF
SERVICE

EMERGENCY SERVICE

T0'11'.LS

YONKERS
CHARGE

NY 10705
ALLOWABLE
AMOUNT

PROVIDER
RESPONSIBILIT'i

243. 00

0. 0(

243. 00

243. 00

0. 00

243. 00

REASON
COOE(S)

002

YOU CA~ LEARN MORE ABOUT THE SERVICES LISTED BY CALLING THE CUSTOMER SERVICE PHONE NUMBER ON THE
BACK 01 YOUR ID CARD. WE CAN TELL YOU THE DIAGNOSIS AND TREATMENT CODES INCLUDED ON YOUR CLAIM,
ALONG W TH THE DESCRIPTIONS FOR THOSE CODES.

REASON CODE
00:1

REASON CODE TEXT

THIS IS A DUPLICATE CLAIM. TO INQUIRE ON THE STATUS OF THE ORIGINAL CLAIM, PLEASE
CONTACT THE CUSTOMER SERVICE NUMBER LOCATED ON THE BACK OF THE MEMBER'S ID CARD OR
ACCESS OUR WEBSITE AT THE ADDRESS LISTED BELOW.

DEDUCTIBLE

ADDITIONAL
COPAY/
MEMBER
COINSURANCE RESPONSIBILITY

REASON
CODE(S)

AMOUNT
PAIDTO
PROVIDER

0. 00

0 . 00 I
0 . 00

0. 00

0. 00

0. 00

0. 00

0 . 00

0. 00