Balance Billing Protection Act

One of the most significant changes to healthcare legislation in Washington State is the Balance Billing Protection Act. This Act is geared towards protecting consumers from unexpected charges and financial burdens in relation to out-of-network care. The Act began on January 1st, 2020, preventing the balance of billing for emergency services and particular procedures performed by out-of-network physicians in in-network facilities.

The legislation applies to fully insured and self-insured health plans that comply with the law. The Balance Billing Protection Act is a major step towards protecting consumers in healthcare and creates more transparency in healthcare billing practices.

What is Balance Billing

Balance billing, commonly known as “surprise billing,” happens when an individual receives care from an out-of-network provider or facility and is billed for the difference between the provider’s charge and the allowed amount on the patient’s insurance plan.

This process often leads to unexpected charges and deep financial burners for patients. This is particularly true in an emergency, where the patient has little to no say in the provider.

Comparison with Federal Law

The federal law known as the No Surprises Act is similar to the Balance Billing Protection Act in the sense that they each work towards protecting consumers from unexpected charges related to out-of-network care. Despite their similarities, there are a few major differences between the two forms of legislation.

  • Scope of Protection 

In several situations, the No Surprises Act protects consumers with private health insurance from out-of-network surprise bills. At the same time, the Balance Billing Protection Act prohibits balance billing for emergency services.

  • Consent and Notice Requirements

The No Surprises Act allows for balance billing in certain providers as long as the patient consented to the balance. Furthermore, the patients must have received an easy-to-understand notice with a good-faith estimate of costs. However, the Balance Billing Protection Act does not specifically cover this section.

  • Dispute Resolution Process

Further discrepancies between the two legislations regard the resolution process. The No Surprises Act has a process for settling payment disputes between consumers or providers, which aims to take patients out of payment disputes. On the other hand, the Balance Billing Protection Act could impact the resolution of payment disputes between payers and providers.

Impact on Healthcare Providers

The Balance Billing Protection Act could majorly impact the healthcare providers in Washington State. This Act could have many implications on healthcare; here are the most likely potential impacts:

  • Reimbursement and Financial Impact

Decreasing Medicare reimbursement rates and the expansion of Medicaid patients, along with the decreasing number of providers, could increase the financial challenges for healthcare providers.

  • Access to Care

The Balance Billing Protection Act could change how healthcare providers interact with insurance plans, ultimately changing patient access to care.

  • Social Determinants of Health

The Act’s impact on healthcare providers intersects with broader efforts to address social determinants of health and improve overall health and health equity in the state, potentially influencing how providers deliver care and allocate resources.

Consumer Protections and Rights

The Balance Billing Protection Acts could have many major consumer protection and rights implications. The Act includes balance billing prohibitions for particular services, a process to dispute payments for out-of-network services, and many communication and transparency requirements. Thanks to these changes, consumers are provided with greater transparency and protection in healthcare billing practices.

Along the lines of billing, the Act creates guidelines to protect consumers from being billed for the balance of charges not covered by their insurance. This impacts consumers the most in situations where they have little control over the healthcare providers, like emergencies or accidental treatment by out-of-network providers working at an in-network facility.

Additionally, the dispute process of payments for out-of-network services acts as a layer of protection for consumers from financial disputes. It also serves as a mechanism for addressing billing discrepancies. By creating these protections and specific rights, the Act aims to empower consumers, mitigate financial uncertainty, and promote greater confidence in healthcare accessibility.

Challenges of the Balance Billing Protection Acts

Despite the advantages of the legislation, it does come with a number of challenges and considerations for healthcare providers and consumers as well.

  • Billing Practices and Reimbursement

First and foremost, healthcare providers could run into issues ensuring their billing practices comply with the new legislation. The Act could force adjustments to how providers bill and collect payments for out-of-network services. This change could even impact their revenue streams and financial arrangements.

  • Dispute Resolution and payment Mechanisms

The dispute process established in the Act could create challenges for healthcare providers in processing payment disputes with insurers. The providers could be forced to engage in formal dispute resolution processes, adding another complex layer to the financial interactions.

  • Compliance and Enforcement

Each healthcare provider is compelled to follow the Act to a tee. Failure to comply with the requirements could lead to action by the regulatory authorities.

  • Impact on Patient Interactions

A lasting impact of this Act could drastically change how the healthcare provider interacts with the patient. The providers must ensure that patients are informed of their rights under the law and are protected from unexpected charges.

Enforcement and Compliance

There are a few enforcement and compliance aspects of the legislation to ensure healthcare provider compliance in Washington.

State Enforcement Authority: The Balance Billing Protection Act will require enforcement to ensure compliance with healthcare providers and insurers. Protection for consumers is already established due to the No Surprises Act, reflecting the state’s responsibility to oversee and enforce the requirements of the Act.

Impact on Payment Mechanisms: The Act could influence the payment process between providers and insurers. The health care providers  and health insurer must comply with the Act’s provisions, including the dispute resolution process, to protect consumers from unexpected charges and financial disputes related to out-of-network care.

Conclusion

Overall, the Balance Billing Protection Act is an essential step toward protecting consumers from unexpected charges and financial burdens in relation to out-of-network care. This Act covers balance billing prohibitions for many services, payment dispute resolution processes, and various communication and transparency requirements. By establishing clear guidelines and protections, the legislation aims to mitigate financial uncertainty and promote greater confidence in accessing healthcare services without fearing unexpected and excessive charges. As the Act continues to shape the healthcare landscape in Washington State, its impact on consumer rights and protections underscores the state’s commitment to fostering a more equitable and transparent healthcare billing environment, ultimately benefiting the well-being of individuals across the state. For more information visit our website or contact us today!