N.Y. Financial Services Law Section 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 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.

Source: Section 604 — Criteria for determining a reasonable fee, https://www.­nysenate.­gov/legislation/laws/FIS/604 (updated Apr. 22, 2022; accessed Jan. 4, 2025).

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Accessed:
Jan. 4, 2025

Last modified:
Apr. 22, 2022

§ 604’s source at nysenate​.gov

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