A bill to help cut down on unexpected medical bills is advancing through the Legislature.
The measure would require insurance carriers to cover emergency services provided at out-of-network emergency departments. It also would require carriers to cover non-emergency care if it is received at an in-network facility. (For example, insurers would have to pay an out-of-network anesthesiologist for services at a in-network hospital.)
On March 4 the bill passed the House 84-13. The measure recently advanced through two Senate committees and is headed to the chamber floor for a vote.
One of five Americans admitted to an emergency room receive a so-called “surprise bill” for out-of network care, according to the state Office of the Insurance Commissioner. In most cases, the patient either unknowingly gets treatment at an in-network hospital from an out-of-network provider or is treated at an out-of-network facility because of the severity of the emergency, the Insurance Commissioner’s Office said.
Surprise billing has been a problem for many years but has grown over the last five or six years, said Steve Valandra, an Insurance Commissioner spokesman. The department didn’t have specific numbers for Cowlitz County, but Valandra said surprise billing happens across the state.
La Center resident Jamie Hansen got stuck with $110,000 in bills for out-of-network emergency care for her son’s heart infection. In an Insurance Commissioner video, Hansen said she knew the hospital wasn’t included in her insurance plan but couldn’t go to a different emergency room at the time due to the urgency of her boy’s condition.
One reason why the problem is on the rise is because insurers developed narrower networks when the Affordable Care Act took effect, Valandra said. A network is a group of providers that contract with a health plan to provide services to its members at negotiated rates. Valandra said patients are not always aware what medical providers are in their networks.
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“Those things change all time throughout the year,” he said. “People have to be vigilant when looking at plans.”
Another factor is that when insurance companies set up contracts with providers, some accept the rate that insurance company will pay and others won’t, leaving the difference to patients, Valandra said.
“Anesthesiologists will stand out because there’s not enough of them around and they have leverage over what they can charge,” he said.
State law already requires insurance plans to cover emergency services at an out-of-network facility, but only if the services were necessary to screen and stabilize the patient. The bill would change the law to require insurance companies to cover out-of-network emergency services regardless of whether going to an in-network department would result in a delay.
The bill also requires the Insurance Commissioner to create a notice of the balance billing rules for health carriers, providers and facilities to post online. Hospitals and providers must also list health plans that they are included in on their websites.
The balance billing prohibition measure doesn’t apply to everyone with insurance. Medicaid isn’t covered and a self-funded group health plan can elect to participate.
Federal legislation to end surprise billing is also in the works but hasn’t been introduced yet this year.