Lately, you may have heard about surprise medical billing in the local and national news.  I'm thrilled both Washington D.C. and Washington state are finally giving this issue the attention it deserves, because it is one of the most costly and troublesome issues I see for health insurance consumers.  For most of us, the only 'surprise' we want on our medical bill, is to hear either we don't owe anything after all or insurance decided to cover it.  But the reality is, 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.

A common concern we get at PNW Insurance Solutions, located in Mukilteo, WA is something along the lines of "I went to an in-network hospital, so why do I owe this HUGE amount still?" Well, this happens because some types of providers, including anesthesiologists, radiologists, pathologists, and labs may not be contracted with your insurance company 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.  This is commonly referred to as 'balance billing'.  

So, what is Washington state doing about this?  Quite a bit actually.  Beginning January 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. How great is that?!? 

This new law will provide 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. At last, some long needed help!

This new law will provide 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. More protection for us!

There will be a new sheriff in town. 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. Bam!

So what should you do before the law is enacted if this happens? 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 you reduce your costs. Stand up for yourself!

If you have any questions, please contact Wendee Allen at PNW Insurance Solutions 425-314-0988.