Surprise or 'balance' billing happens when you're treated for an emergency or have a scheduled procedure at an in-network hospital or surgery facility and are seen by an out-of-network provider.
It happens because some types of providers, including anesthesiologists, radiologists, pathologists, and labs may not be contracted with your insurer even though they provide services at a hospital or facility that is in your health plan’s provider network. So, in addition to your expected out-of-pocket costs, you also get a bill for the difference between what your insurer has agreed to pay that provider and the amount the provider billed for their services. Commissioner Kreidler believes this is unfair and requested legislation to protect consumers from surprise medical bills. His request bill, the Balance Billing Protection Act passed the legislature in April, 2019.
Balance Billing Protection Act takes effect Jan. 1, 2020
The new Balance Billing Prevention Act prevents people from getting a surprise medical bill when they receive emergency care from a hospital or get care at an in-network facility but are treated by an out-of-network provider. If an insurer and provider cannot agree on a price for the covered services, they go to arbitration and cannot bill the consumer for the amount in dispute. Other key parts of the law include:
Transparency - Insurers, medical providers and facilities must give consumers a new notice detailing their rights and letting them know when they can and cannot be balance billed. Also, they must keep updated information about provider networks on their websites.
Dispute resolution - The amount an out-of-network provider will be paid by an insurer must be a "commercially reasonable" amount based on payments for the same or similar service in a similar geographic area. If an insurer and provider cannot reach an agreement, either one can request arbitration. Neither one can involve the consumer in the dispute.
Enforcement - If the commissioner's office sees that a provider is continuing to surprise bill consumers, it can refer the provider to the Department of Health for disciplinary action.
Commissioner Kreidler's office has started the rulemaking process to implement the new law. A stakeholder draft of the proposed rule (PDF, 272KB) is available for comment until Aug. 16.
Advice for consumers who get a surprise bill before Jan. 1, 2020
If you get a surprise medical bill before the new law takes effect, you should contact the provider directly. Tell them you know the law is changing soon and ask them to reconsider the charges or request a reduced charge. Unfortunately, surprise billing could still occur in this time, but knowing your options could help your reduce your costs.
Watch Jamie Hansen of La Center, WA tell her surprise billing story when her son, Ryan had a medical emergency.
Balance Billing Protection Act implementation - arbitrators
Section 8 of the Balance Billing Protection Act (Chapter 427, Laws of 2019) directs the Office of the Insurance Commissioner (OIC) to develop a list of approved arbitrators or entities that provide arbitration for use by parties involved in balance billing disputes. The act calls for arbitrators to preside over disputes between health care providers, facilities and carriers.
The OIC is seeking stakeholder input on the minimum qualifications of arbitrators for inclusion on the OIC list and the processes to implement section 8 of the act.
Stakeholder input letter released Aug. 16, 2019
Please submit comments by Aug. 30 to the OIC rules coordinator.