The Washington State Hospital Association (WSHA), Washington State Medical Association (WSMA), and insurance carriers have a final agreement on amendments to House Bill 1065 – the Office of the Insurance Commissioner’s (OIC) bill to protect patients from unexpected out of network charges in certain situations. We believe a final version of the bill will be passed out of committee sometime today and will ultimately be passed by the legislature. The bill has undergone significant improvement through our efforts. WSHA’s Out of Network Task Force provided WSHA with valuable member input during this process.
Overall, the bill restricts balance billing of out of network emergency services and certain out of network services provided at an in-network facility and establishes a dispute resolution process between carriers and providers for out of network services on disputed claims. Features of the final bill:
- No default payment rate for out of network services. Carriers are required to reimburse out of network services within the scope of the act at a commercially reasonable rate. Disagreements regarding payment level between carriers and providers are addressed through a dispute resolution/arbitration process.
- Removes Medicare rate as an arbitration criterion and allows bundling of similar claims with the same carrier incurred within a two-month period.
- Addresses the ERISA problem by allowing self-insured health plans to opt-in to the balance billing protections and payment requirements of the law by registering with the OIC. Requires carriers and group administrators to make available to hospitals and providers information regarding whether a patient’s coverage is subject to the act through their normal eligibility verification processes.
- Requires direct payment from carriers to hospitals and physicians for out of network services subject to the act.
- Strengthens network adequacy requirements for carriers, specifically that they have adequate networks of physicians providing services at in-network hospitals.
- Includes workable transparency requirements for hospitals and physician groups. Hospitals and physicians will need to post on their website a listing of the carrier networks with which they are in network but can rely on the information provided by carriers in their provider contract.
WSHA will provide more specifics regarding the details of the bill and hospital and provider implementation once it is finalized. (Andrew Busz, andrewb@wsha.org)
