How to Pay In-Network Rates for Out-Of-Network Care

Consumer Questions and Complaints

If you are unable to find the answer to your questions here, check our FAQs. If you are still having trouble, you can file a complaint or contact us for further assistance:

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What to do if you get a surprise bill

If you get a surprise medical bill for a services you had before Jan. 1, 2020, contact the provider or facility and tell them your concerns. See if you can get them to lower your bill. After Jan. 1, 2020, you cannot be surprise billed for certain services. If you get a surprise bill, contact the provider or facility and tell them you believe you’ve been wrongly billed. You can also file a complaint with our office and we will investigate on your behalf. 

Watch a webinar (www.vimeo.com) on Washington’s Balance Billing Protection Act.

Video

What health insurers must do 

  • Base your cost-sharing responsibility on what it would pay an in-network provider or in-network facility in your area and show the amount on your Explanation of Benefits (EOB). 
  • Count any amount you pay for emergency services or certain out-of-network services toward your deductible and out-of-pocket limit.
  • Tell you, via their websites or if you ask, which providers, hospitals and facilities are in their networks.
  • Provide notice to you (PDF, 135.68 KB) detailing your rights under the balance billing protection act and letting you know when you can and cannot be balanced billed.

Common Surprises That Complicate Insurance Billing

Even if you do your best to choose in-network hospitals and doctors, you may be met one day with a surprise out-of-network bill.

For example, if you experience a medical emergency, you could be taken to and treated at the nearest hospital regardless of whether it’s in-network. Or if you’re having surgery at an in-network hospital, the anesthesiologist or assistant surgeon could still be out-of-network. If this happens, you could be left with a bill for the difference between what the provider charges and what your insurance pays, which is known as “balance billing.”

Fortunately, the No Surprises Act will take effect in 2022, protecting people from most of these types of surprise bills. “This legislation will mean that consumers will no longer be left on the hook for out-of-network charges in emergency situations or if they receive care from an out-of-network provider while at an in-network facility,” Norris said.

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Is there a limit to how much out-of-network doctors can charge?

When doctors contract with health insurance companies as part of a provider network, they typically agree to offer discounted rates to that health plan’s members. But out-of-network doctors aren’t limited by the same contractual obligations, Plus, an out-of-network provider’s charges won’t apply toward your plan’s out-of-pocket maximum, so you could pay far more than what you would have for in-network charges.

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