The routine is familiar for most people: When checking in for an appointment with a doctor or other health care provider, patients typically complete and sign a pile of paperwork, including a form that contains some version of the statement, "I agree to pay for all charges not covered by my insurance company."
Patients may not feel comfortable making that financial promise, often before they have any idea what the charges will be. But they generally sign the form anyway, because the alternative is often not to get the services they're seeking.
As a result, consumers may be responsible for unexpected bills and at risk for medical debt.
In New York, state officials, advocates and the health care provider community have been engaged in a policy tug-of-war over efforts to protect consumers. Patient advocates don't want them to get stuck signing blank-check forms that put them in financial jeopardy. Doctors, hospitals and other providers don't want to disrupt their practices' workflow and payment logistics with cost discussions and paperwork, especially after services have been provided.
State officials' efforts to find a satisfying compromise have so far fallen short.
At the center is a state law that took effect last fall to prohibit requiring patients to sign such consent-to-pay forms before they've received treatment and discussed the costs.
Legal analysts described it as the first such law in the country. Physician groups cried foul, saying it would raise payment issues and other significant logistical problems.
Those concerns found traction. Shortly before the law's start date, the state's health department delayed its implementation indefinitely. In addition, Democratic Gov. Kathy Hochul's proposed fiscal year 2026 budget would let providers go back to requiring patients to agree to pay for care in advance of receiving treatment. It also clarified that the consent requirements would not apply to emergency care.
A key provision of the new law would remain in place, however: Doctors and other providers would still be obligated to have the cost discussion with patients before the patient is asked to sign the form agreeing to pay for the service.
Debate over price transparency
Some consider even the remaining provision a significant step.
"Providers having an affirmative obligation to discuss treatment costs is unique," said Gregory Mitchell, a partner in the health and life sciences practice group at McDermott Will & Emery law firm who specializes in managed care. Clients from around the country have been reaching out to the law firm with questions.
Requiring providers to discuss costs with patients, whether before or after services are provided, would pose a "significant burden," he said. Doctors and other providers typically don't know specifics about patient deductibles, cost sharing or other insurance coverage details until after a claim is submitted to a health plan.
Health care services are different than refrigerators or other goods that people buy, doctors say. If a patient gets a colonoscopy and doesn't want to pay for it, "it's not possible to take the service back," said Jerome Cohen, a gastroenterologist and the president of the Medical Society of the State of New York, which represents physicians.
As for the proposed changes in the 2026 budget, Cohen said the medical society "very much appreciates the governor's efforts to try to fix this problematic financial consent requirement."
But patient advocates are pushing back. The current practice is "unfair and it's wrong," said Elisabeth Benjamin, vice president of health initiatives at the Community Service Society of New York, a nonprofit that has successfully pushed for passage of several medical debt-related laws in recent years. No patient should ever have to preemptively agree to pay whatever a provider charges, Benjamin said.
In a written response to questions, Danielle De Souza, a spokesperson for the New York Department of Health, said that the proposed law change is justified, "given the burden of this requirement on both patients and providers." De Souza didn't respond to a request for clarification about what those patient burdens are.
'Like signing a consent to be scammed'
Helen Krim walked out of a doctor's office in the Bronx borough of New York City a few years ago rather than sign an open-ended form agreeing to pay for any services recommended by the doctor.
It was the first time that Krim, who is covered by Medicare, had visited that primary care practice. When she told them she didn't want to sign the form, she was told they wouldn't serve her unless she did.
"I'm one of those annoying people who actually reads the forms," the retired bank project manager said. "It's kind of like signing a consent to be scammed." She found another practice that didn't ask her to sign a similar form.
There are other consumer medical debt protections at the federal and state level. The federal No Surprises Act restricts providers from billing consumers for out-of-network services in certain instances. It also requires providers to give good-faith cost estimates for self-pay patients. The Consumer Financial Protection Bureau released a final rule in January that would have removed medical debt from people's credit reports, but the rule's implementation has been frozen by the Trump administration.
Several states besides New York have also taken steps to protect consumers with medical debt.
Benjamin said that simply requiring an unspecified "discussion" about costs doesn't address patients' potential unlimited financial liability. Under a bill that Benjamin's organization has drafted, providers would have to give patients a written good-faith estimate of their expected costs before the patient receives services and patients could not be held liable for unlimited or unspecified costs beyond that estimate.
"Let's be the first state to really have fair rules of engagement for both the providers and the patients about what is it that you're agreeing to be financially liable for at the point, beforehand," Benjamin said.
So far, though, the measure has not been introduced, with the focus in Albany on the governor's budget proposal.
Providers, too, are taking a wait-and-see attitude, Mitchell said, because the budget plan must still move through the legislative process.
Another New York medical debt-related law that took effect in October takes aim at the use of credit cards to pay for medical services. The Hochul administration has not proposed changing it. The law prohibits providers from requiring pre-authorization of credit cards or keeping a patient's card on file. It also requires providers to notify patients of the risks of paying for medical care with credit cards, which may lack medical debt protections. In addition, providers aren't allowed to help patients complete credit card applications under the law.
The laws are aimed at stopping unfair billing practices and reducing medical debt for New Yorkers. Earlier laws ban credit reporting of all medical debt, prohibit hospitals from suing patients with incomes under 400% of the poverty level, among other things.
New York providers don't like the credit card law either, though it hasn't generated the pushback seen with the consent-to-pay law.
In a statement, Brian Conway, a spokesperson for the Greater New York Hospital Association, said: "It's important to clarify that hospitals do not oppose the goals of the hospital financial assistance law reforms overall, but rather the operational burdens and patient disclosure overload that a few specific provisions create."
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF .
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