Washington addresses concerns with surprise health care bills

The Washington legislature recently enacted the Washington Out of Network Health Care Services Balance Billing Protection Act. Taking effect Jan. 1, 2020, the law requires fully insured groups sitused within the state of Washington to comply with certain arbitration requirements in disputes with OON providers and facilities. 

Self-funded (ASO) groups that elect to opt in will also need to comply with arbitration requirements.

The Act covers those services a member receives from Washington providers, including doctors, hospitals, ambulatory surgery centers and other health professionals that are not part of the member’s health plan network. The process applies to:

  • Emergency services provided to an enrollee in Washington, Idaho or Oregon.
  • Non-emergency services provided in Washington at a network hospital or a network ambulatory surgical facility, if services involved surgical or ancillary services and are provided by an OON provider.

Arbitration may be requested by either the carrier or the health care provider. 

Providers cannot bill the member for anything other than applicable deductible, copayment or coinsurance amounts.

The Act does not apply where an individual makes a conscious choice to use an out-of-network provider.

Arbitration

When arbitration has been requested, both parties submit an amount they believe is a commercially reasonable rate for the service provided, along with any supporting materials. The arbitrator makes their determination by selecting the final offer from either party. 

  • The arbitrator’s fee is split evenly between the two parties. 
  • Each party pays their own arbitration expenses.

Applicability and UnitedHealthcare 

The Act is not automatically applicable to self-funded groups. The group must express their intent to be covered by the law by opting in. There is a fee for a self-funded group that opts in based on membership in Washington. Most UnitedHealthcare self-funded clients have out of network programs to support reducing costs through negotiation. 

Before opting in, ASO customers may want to discuss with their stop loss carrier how any binding arbitration award will be treated under the stop loss policy. 

Self-funded groups that choose to opt in will have to change their plan documents to indicate their election.

Contact your UnitedHealthcare representative if you have questions.