Surprise or 'balance' billing can happen 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.
This 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.
New law takes effect Jan. 1, 2020
The new surprise billing law (www.leg.wa.gov) 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 can go to binding arbitration but they cannot bill the consumer for the amount in dispute.
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.
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.
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.
Next steps - need your feedback
We're looking for your feedback on a draft Consumer Notice that will detail when a consumer can and cannot receive a surprise bill. Please submit your feedback by June 20. We will circulate a second draft that reflects your feedback in July. Additional details about the notice, including how it will reach consumers, will be determined during the rulemaking process over the next several months.
Advice for consumers who get a surprise bill before Jan. 1, 2020
Commissioner Kreidler's office will start the rule-making process for the new law in June.
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.