Billing and Insurance

Glens Falls Hospital Charges

Section 2718(e) of the Public Health Service Act requires that each hospital operating within the United States, for each year, establish (and update) and make public a list of the hospital’s standard charges for items and services provided by the Hospital.  Effective January 1, 2021, hospitals are required to make available a comprehensive machine-readable file with all items and services offered by the Hospital and a display of shoppable services in a consumer-friendly format.

To comply with these reporting requirements Glens Falls Hospital is making available a machine-readable version of Glens Falls Hospital’s gross charges, discounted cash prices, payer-specific negotiated charges, and de-identified minimum and maximum negotiated charges ( “Hospital’s Standard Charges”)  as well as a separate Display of Shoppable Services. The Hospital’s Standard Charges and Display of Shoppable Services do not include physician or other separately billable professional provider charges.

A hospital’s gross charge is the dollar amount that is billed to insurance companies; however, it is typically not what a patient will be responsible for paying or what the insurance company pays. A patient’s potential financial liability is dependent on various factors that may include actual charges for services provided, insurer negotiated payment rates, government established payment rates, patient co-insurance and deductible responsibilities, secondary insurance benefits, qualifying financial aid and prompt pay discounts.   

The pricing information contained in the Hospital’s Standard Charges and Display of Shoppable Services are intended to be informational only and are not necessarily reflective of the patient’s final financial liability or the amount that will actually be paid by an insurance plan.  A patient’s final bill will depend on actual services and procedures performed as determined by that patient’s doctor.  Final determination of eligibility and benefits are determined at the time the claim is processed by the insurance plan.

If you have questions or need an estimate for services, please call Christine at 518-926-5111. We recommend that you also contact your insurance plan for information regarding the plan’s payment amount and your patient liability amount or regarding any questions concerning plan benefit restrictions or coverage limitations.

Hospital’s Standard Charges

The Hospital’s Standard Charges include a machine readable file of the following charges. Click here to download the machine readable file:

  • Gross charge: The charge for an individual item or service that is reflected on a hospital’s chargemaster absent any discounts that by law is billed to all insurance companies.
  • Discounted cash price: (Provided to non-insured patients) The Expected Payment that applies to non-insured individuals who pay cash (or cash equivalent) for a hospital item or service.
  • Payer-specific negotiated charge: The PAYMENT that a hospital has negotiated with a third-party payer for an item or service.
  • De-identified minimum negotiated charges: The lowest PAYMENT that a hospital has negotiated with all third-party payers for an item or service.
  •  De-identified maximum negotiated charges: The highest PAYMENT that a hospital has negotiated with all third-party payers for an item or service.
  • THE CHARGE AMOUNT IS TYPICALLY NOT WHAT A PATIENT WILL BE RESPONSIBLE FOR PAYING.

Display of Shoppable Services

The Display of Shoppable Services represents 300 “shoppable services” that a health care consumer can schedule in advance.  Click here to download the Display of Shoppable Services.

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Patient Protections Against Surprise Billing

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayment, coinsurance and/or deductible.

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 copaymentcoinsurance, 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:
    • Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
    • Cover emergency services by out-of-network providers.
    • 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.
    • 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 [email protected]. 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.

For full details on the No Surprise Bill Act and the requirements of insurance companies, care providers and healthcare facilities, please click here.

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Good Faith Estimates

You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost

Under the law, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services. These includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
  • If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.
  • If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.
  • Make sure to save a copy or picture of your Good Faith Estimate and the bill.

For questions or more information about your rights to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers, email [email protected], or call 1-800-985-3059.

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Understanding your Hospital Bill

When you are treated at Glens Falls Hospital or any hospital, you or your insurance provider will receive separate bills from the hospital itself and from any physicians involved in your care. Some of these physicians may be employed by the hospital, others may work for private practices in the community.

The hospital bill will include charges for the use of hospital equipment, supplies and facilities, as well as any services provided by hospital employees other than physicians.

Each physician (or physician practice) involved in your care may issue a separate bill for services provided, such as consultations, procedures and evaluations of medical tests.

Insurance Coverage

Glens Falls Hospital is a participating provider in many health insurance plans. You can find a list of those plans here but we encourage you to check with your insurance company’s member services department to verify coverage. Some health plans use smaller provider networks for coverage of certain products and services, so exclusions may apply.

Physicians involved in your care in the hospital may or may not accept the same insurance plans as the hospital, as follows:

  • Physicians employed by Glens Falls Hospital accept the same plans as the hospital;
  • Private practice specialists may not accept the same plans;
  • Private practice specialists with contractual agreements to provide certain services (anesthesiology, pathology, radiology) within the hospital may not accept the same plans.

We encourage you to check with your insurance company, and/or physician arranging for hospital services, if you have questions about insurance coverage. Click here to view a list of Glens Falls Hospital Contracted Services.

Financial Assistance

If you do not have health insurance, or face difficulties in paying your portion of a hospital bill, you may be eligible for assistance. To learn more, click here or contact our Financial Assistance Office at 518-926-5111.

Understanding Inpatient vs. Outpatient Observation Services

Even if you stay in the hospital overnight, you might still be considered an outpatient.

The decision for inpatient hospital admission is a complex medical decision based on your doctor’s judgment and your need for medically necessary hospital care. An inpatient admission is generally appropriate when you’re expected to need two or more nights of care in the hospital. The attending physician must order such admission and the hospital must formally admit you in order for you to become an inpatient.

Sometimes, however, a doctor may decide to keep you in the hospital as an outpatient for a period of time and he or she may order observation services. When you are an outpatient, you generally do not meet the clinical criteria to be an inpatient, even though you are in a regular hospital bed. The observation services that you receive as an outpatient may look and feel exactly like inpatient services, but costs and insurance coverage will differ. These stays are usually shorter hospital stays that will provide testing, treatments, as well as care by a physician and other hospital staff. When you are being discharged from outpatient status, any further testing may need to be done in the outpatient setting.

Benefits vary greatly for patients with private insurance – it is important to call your insurance company to make sure you understand your co-pays, co-insurance and covered services. If you are a Medicare patient, being on outpatient status may impact what you pay in the hospital and what type of coverage you have when you leave the hospital (see below).

Outpatient Observation Insurance Coverage Under Medicare

If you are covered by Medicare, either traditional Medicare or a Managed Care Medicare Advantage Plan, being an outpatient may impact what you pay in the hospital and what type of coverage you have when you leave the hospital.

When designated as being an outpatient, you will receive a notice titled “Medicare Outpatient Observation Notice,” which provides an overview of coverage. You can read a copy of this notice here.

If you have any questions about your outpatient services, ask the hospital staff member giving you the notice or the doctor providing your hospital care. You can also ask to speak with someone from the Glens Falls Hospital Care Management department, or call 800-MEDICARE (800-633-4227). TTY users should call 1-877-486-2048.

Provider-Based Services & Billing

Glens Falls Hospital owns and operates a number of physician practices in the region which are designated as “Hospital-based” or “Provider-based” outpatient clinics under federal Medicare rules and by some private health insurance companies. When we care for someone at these provider-based clinics, we issue two separate bills— one bill for the physician’s services, and another bill to cover our costs of running the facility. Depending on a patient’s health insurance coverage, this may result in higher out-of-pocket costs from co-pays and deductibles. Patients should contact their insurance company to determine their coverage for hospital-based facility charges. Patients can also call the location before the visit to find out if they are a hospital-based clinic.

Glens Falls Hospital understands that federal billing guidelines are complex and patients may have questions. For help understanding charges associated with Glens Falls Hospital, contact the Patient Accounting team at 518-926-5111.

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