December 22, 2015

Michael J. Fara 139 Livingston Avenue

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

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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

Dear Doctor:

Department of Health

HOWARD A. ZUCKER, M.D., J.D. Acting Commissioner

March 16, 2015

SALL V DRESLIN, M.S., R.N. Executive Deputy Commissioner

Re: Revised Effective Date

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 I health.ny.gov

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CHECK NUM!ll;IR:

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

0042699770

FARA. MICHAEL J 05062375DFE081124

907A78942 CLARIDGE-WEISSE, J

2015259CK7126 OUT OF NETWORK

09/16/2015 09/22/2015

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THIS IS NOT A BILL YOUR BENEFIT SNAPSHOT'

BENEFIT AMOUNT MET-AMOUNT YEAR TO DATE

BENEFIT YEAR 2015 INDIVIDUAL IN-NETWORK OUT-OF-POCKET-LIMIT 2,000. 00 230. 00 FAMILY-IN-NETWORK OUT-OF-POCKET-LIMIT 4,000. 00 230. 00

REMAINING BALANCE

1,770. 00 3, 770. DO

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

FARA, MICHAE.. J 139 LIVINGSTOl'J AVE YONKERS NY 10705

DATE(\) OF TYPE OF ALLOWABLE PROVIDER REASON CODES CHARGE SER"I\ICE SERVICE AMOUNT ~ESPONSIBILIH CODE(S)

09/06/2015-19/06/2015 99283 EMERGENCY SERVICE 243. DO 62. 8! 180. 12 45

TOilLS 243. 00 62. 88 180. 12

YOU CAIi LEARN MORE ABOUT THE SERVICES LISTED BY CALLING THE CUSTOMER SERVICE PHONE NUMBER ON THE BACK o• 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 EXPLANATION

DEDUCTIBLE

0.00

0.00

000251 N 45 CHARGE EXCEEDS FEE SCHEDULE/MAXIMUM ALLOWABLE OR CONTRACTED/LEGISLATED FEE ARRANGEMENT.

COPAY/ ADDITIONAL REASON MEMBER COINSURANCE RESPONSIBILITY CODE(S)

0. 00 I 0. 00 0. 00

0.00 0.00

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AMOUNT PAID TO MEMBER

62. 88

62. BB

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CHECK NUMBER:

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

NA

FARA,MICHAEL J 05062375DFE100442

907A7B942 CLARIDGE-WEISSE, J

2015352BK2882 OUT OF NElWORK

12/18/2015 12/22/2015

0.00

THIS IS NOT A BILL YOUR BENEFIT SNAPSHOT'

BENEFIT AMOUNT MET- REMAINING BENEFIT YEAR 2015 AMOUNT YEAR TO DATE BALANCE

INDIVIDUAL IN-NETWORK OUT-OF-POCKET-LIMIT 2,000. 00 328. 78 1,671 . 22 FAMILY-IN-NETWORK OUT-OF-POCKET-LIMIT 4, 000. 00 328. 78 3, 671 . 22

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

FARA, Ml CHAil J 139 LIVINGSTON AVE YONKERS NY 10705

DATE(S) OF TYPE OF ALLOWABLE PROVIDER REASON CODES CHARGE SER~CE SERVICE AMOUNT RESPONSIBILIT'i COOE(S)

09/06/2015-09/06/2015 99283 EMERGENCY SERVICE 243. 00 0. 0( 243. 00 002

T0'11'.LS 243. 00 0. 00 243. 00

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.

COPAY/ ADDITIONAL REASON DEDUCTIBLE MEMBER COINSURANCE RESPONSIBILITY CODE(S)

0 . 00 I 0. 00 0 . 00 0. 00

0. 00 0. 00 0 . 00

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.

AMOUNT PAIDTO

PROVIDER

0. 00

0. 00