N.Y. Financial Services Law § 604

* § 604. Criteria for determining a reasonable fee. In determining the\nappropriate amount to pay for a health care service, an independent\ndispute resolution entity shall consider all relevant factors,\nincluding:\n (a) whether there is a gross disparity between the fee charged by the\nphysician for services rendered as compared to:\n (1) fees paid to the involved physician for the same services rendered\nby the physician to other patients in health care plans in which the\nphysician is not participating, and\n (2) in the case of a dispute involving a health care plan, fees paid\nby the health care plan to reimburse similarly qualified physicians for\nthe same services in the same region who are not participating with the\nhealth care plan;\n (b) the level of training, education and experience of the physician;\n (c) the physician's usual charge for comparable services with regard\nto patients in health care plans in which the physician is not\nparticipating;\n (d) the circumstances and complexity of the particular case, including\ntime and place of the service;\n (e) individual patient characteristics; and\n (f) the usual and customary cost of the service.\n * NB Effective until January 1, 2020\n * § 604. Criteria for determining a reasonable fee. In determining the\nappropriate amount to pay for a health care service, an independent\ndispute resolution entity shall consider all relevant factors,\nincluding:\n (a) whether there is a gross disparity between the fee charged by the\nphysician or hospital for services rendered as compared to:\n (1) fees paid to the involved physician or hospital for the same\nservices rendered by the physician or hospital to other patients in\nhealth care plans in which the physician or hospital is not\nparticipating, and\n (2) in the case of a dispute involving a health care plan, fees paid\nby the health care plan to reimburse similarly qualified physicians or\nhospitals for the same services in the same region who are not\nparticipating with the health care plan;\n (b) the level of training, education and experience of the physician,\nand in the case of a hospital, the teaching staff, scope of services and\ncase mix;\n (c) the physician's and hospital's usual charge for comparable\nservices with regard to patients in health care plans in which the\nphysician or hospital is not participating;\n (d) the circumstances and complexity of the particular case, including\ntime and place of the service;\n (e) individual patient characteristics; and, with regard to physician\nservices,\n (f) the usual and customary cost of the service.\n * NB Effective January 1, 2020\n