For Consumers

What consumers need to know about surprise or balance billing

Starting Jan. 1, 2020, Washington state law protects you from surprise or balance billing if you receive emergency care at any medical facility or when you're treated at an in-network hospital or outpatient surgical facility by an out-of-network provider. 

What is surprise or balance billing?

Surprise billing happens because some types of medical providers, including anesthesiologists, radiologists, pathologists, and labs may not be contracted with your health 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. 

The new Balance Billing Protection Act prevents people from getting a surprise medical bill when they receive emergency care from any hospital or if they have a scheduled procedure an in-network facility and receive care from an out-of-network provider. In this case, 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.

What to do if you get a surprise bill

If you get a surprise medical bill for a services you had before Jan. 1, 2020, contact the provider or facility and tell them your concerns. See if you can get them to lower your bill. After Jan. 1, 2020, you cannot be surprise billed for certain services. If you get a surprise bill, contact the provider or facility and tell them you believe you've been wrongly billed. You can also file a complaint with our office and we will investigate on your behalf. 

The law applies to most, but not all health plans 

The Balance Billing Protection Act applies to all state-regulated health plans and state and school employee benefit plans. Self-funded group health plans are not regulated by the state and must notify us if they want to opt-in to the law and offer the protections to their enrollees.  

See a current list of self-funded group health plans that have selected to follow the new law. 

How much do you pay? 

If you receive a surprise medical bill, you're not responsible for paying it. Your insurer must pay the out-of-network provider and facility directly. You are only responsible for your in-network cost-sharing, including any copays, coinsurance and deductible. 

What health insurers must do 

  • Base your cost-sharing responsibility on what it would pay an in-network provider or in-network facility in your area and show the amount on your Explanation of Benefits (EOB). 
  • Count any amount you pay for emergency services or certain out-of-network services toward your deductible and out-of-pocket limit.
  • Tell you, via their websites or if you ask, which providers, hospitals and facilities are in their networks.
  • Provide notice to you (PDF, 143KB) detailing your rights under the balance billing protection act and letting you know when you can and cannot be balanced billed.

What medical providers and facilities must do

  • Tell you which provider networks they participate in on their website or if you ask.
  • Refund any amount you overpay within 30 business days.
  • Not ask you to limit or give up these rights.
  • Provide notice to you (PDF, 143KB) detailing your rights under the balance billing protection act to let you know when you can and cannot be balanced billed. 

Watch Jamie Hansen of La Center, WA tell her surprise billing story when her son, Ryan had a medical emergency.