1. The Laws of New York
  2. Consolidated Laws
  3. Financial Services Law
  4. Article 6: Emergency Medical Services and Surprise Bills


Section 604 Criteria for determining a reasonable fee

Financial Services Law (FIS)

In determining the appropriate amount to pay for a health care service, an independent dispute resolution entity shall consider all relevant factors, including:

  (a) whether there is a gross disparity between the fee charged by the physician or hospital for services rendered as compared to:

  (1) fees paid to the involved physician or hospital for the same services rendered by the physician or hospital to other patients in health care plans in which the physician or hospital is not participating, and

  (2) in the case of a dispute involving a health care plan, fees paid by the health care plan to reimburse similarly qualified physicians or hospitals for the same services in the same region who are not participating with the health care plan;

  (b) the level of training, education and experience of the physician, and in the case of a hospital, the teaching staff, scope of services and case mix;

  (c) the physician's and hospital's usual charge for comparable services with regard to patients in health care plans in which the physician or hospital is not participating;

  (d) the circumstances and complexity of the particular case, including time and place of the service;

  (e) individual patient characteristics; and, with regard to physician services,

  (f) the usual and customary cost of the service.