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

(a) whether there is a gross disparity between the fee charged by the
provider for services rendered as compared to:
(1) fees paid to the involved provider for the same services rendered
by the provider to other patients in health care plans in which the
provider 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 providers 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 health care
professional, and in the case of a hospital, the teaching staff, scope
of services and case mix;
(c) the provider's usual charge for comparable services with regard to
patients in health care plans in which the provider is not
participating;
(d) the circumstances and complexity of the particular case, including
time and place of the service;
(e) individual patient characteristics;
(f) the median of the rate recognized by the health care plan to
reimburse similarly qualified providers for the same or similar services
in the same region that are participating with the health care plan; and
(g) with regard to physician services, the usual and customary cost of
the service.

Structure New York Laws