2019 New York Laws
FIS - Financial Services Law
Article 6 - Emergency Medical Services and Surprise Bills
604 - Criteria for Determining a Reasonable Fee.

* § 604. Criteria for determining a reasonable fee. 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 for services rendered as compared to:
  (1) fees paid to the involved physician for the same services rendered
by the physician to other patients in health care  plans  in  which  the
physician 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  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;
  (c) the physician's usual charge for comparable services  with  regard
to  patients  in  health  care  plans  in  which  the  physician  is not
participating;
  (d) the circumstances and complexity of the particular case, including
time and place of the service;
  (e) individual patient characteristics; and
  (f) the usual and customary cost of the service.
  * NB Effective until January 1, 2020
  * § 604. Criteria for determining a reasonable fee. 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.
  * NB Effective January 1, 2020