Surprise medical bills and balance billing: Member rights and protection

“Surprise billing” is an unexpected balance bill. This can happen when a member can’t control who is involved in their care. For instance, an emergency situation might involve treatment at an out-of-network facility or by an out-of-network provider.

Out-of-network providers may be permitted to bill a member for the difference between what their plan agreed to pay, and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward the annual out-of-­pocket limit.

As a result, a member may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. There may also be other costs if the provider or health care facility isn’t in their health plan’s network. However, members are protected from balance billing for emergency services. The most a provider can bill them is their plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, surgeons and assistant surgeons, hospitalists, or intensivist services.  

In addition, insurers are required to disclose — via their websites or on request — which providers, hospitals, and facilities are in their networks. Hospitals and surgical facilities must also tell you which provider networks they participate in on their website or on request.

If a member believes they’ve been wrongly billed, they may file a complaint with the federal government at https://www.cms.gov/nosurprises/consumers or by calling 1-800-985-3059; and/or file a complaint with the Washington State Office of the Insurance Commissioner or by calling 1-800-562-­6900.

To learn more, read the Kaiser Permanente Washington BBPA notice.

All plans offered and underwritten by Kaiser Foundation Health Plan of Washington or Kaiser Foundation Health Plan of Washington Options, Inc.

© 2021 Kaiser Foundation Health Plan of Washington