Legislators and the Washington State Insurance Commissioner, Mike Kriedler, are planning legislation for the 2017 legislative session to address the issue of balance billing of patients for services provided outside of the health plan’s network. Legislation was considered last year but did not end up passing. Now the issue is back. The legislators and Commissioner Kriedler are concerned about protecting patients when they receive services at a contracted facility, but related professional or ancillary services are provided by independent providers that are not contracted with the health plan. In these cases, patients are “surprised” to get a bill from the provider based on the provider’s charges. The legislative efforts have focused on protecting the patients from these large and unexpected bills. A number of other states have passed legislation to provide protections.
On August 11, Mike Kreidler and Representative Eileen Cody convened a stakeholder group including WSHA, WSMA, and representatives of provider groups and health plans to discuss the issue. Among the possible solutions discussed at the meeting and communicated via stakeholder draft bill enhanced notification and responsibility to ensure services were provided at in-network providers, and a prohibition against balance billing. The prohibition applies not only in the ER but also extends to all services at an in-network hospital and in addition applies to cases when a patient is referred by an in-network provider to an out-of-network provider. The draft bill establishes a default payment rate for situations involving non-contracted providers, and a mediation process between health plans and providers if they chose to appeal the default rate. Much of the discussion at the meeting focused on the appropriate default rate. The initial draft set it at a percentage of Medicare – at a level that will be very problematic for the providers.
WSHA is concerned about impact to hospitals, particularly if the legislation applies beyond emergency services. We are interested in hearing from our hospital members on this issue. (Andrew Busz, email@example.com)