Washington IDR Arbitration For Medical Revenue Recovery

Washington Surprise Billing Law (SBL)

The Washington Surprise Billing Law (SBL) took effect on January 1, 2020, as outlined in RCW 48.49.030(2). This law establishes protections for patients from surprise medical bills and provides a framework for resolving reimbursement disputes between healthcare providers and insurers for out-of-network (OON) services.

Key Provisions of the Washington SBL

1. Reimbursement Standards:
   • Reimbursement is tied to Usual, Customary, and Reasonable (UCR) rates, considering various factors to determine what is “commercially reasonable.”
2. Negotiation and Arbitration:
   • A 30-day negotiation period is provided for resolving disputes between providers and carriers.
   • If no resolution is achieved, arbitration can be initiated, although the law does not specify a timeline for commencing arbitration after the negotiation period ends.
3. All-Payer Claims Database (APCD):
   • Parties involved in the dispute may consult the APCD for data to support their position.
4. Notice Requirements:
   • Insurance carriers must notify providers if a claim is subject to the No Surprises Act (NSA) provisions.

Scope of Application

The Washington SBL applies to:

• Emergency services (screening and stabilization) provided at a hospital.
• Nonemergency services, including surgery, radiology, anesthesiology, pathology, hospitalist care, and laboratory services, provided by out-of-network providers at in-network hospitals or ambulatory surgical facilities.

State and Federal Coordination

1. Specified State Laws:
   • Washington’s specified state laws govern OON rate determinations for services within the SBL's scope.
2. Federal Independent Dispute Resolution (IDR) Process:
   • The federal IDR process under Sections 2799A-1(c) and 2799A-2(b) of the Public Health Service (PHS) Act applies for items and services not covered by Washington’s specified laws, including:
     • OON services for individuals in insured group health plans or individual health insurance coverage.
     • Air ambulance services provided by nonparticipating providers.
3. CMS Enforcement:
   • CMS enforces the federal IDR process outcomes for cases not governed by Washington’s SBL.
4. Washington State Enforcement:
   • The Washington Office of the Insurance Commissioner oversees the enforcement of the federal IDR process within the state.

CMS Clarifications

In a letter from CMS to the Governor of Washington (December 21, 2021), CMS clarified:

• Washington does not have an All-Payer Model Agreement to determine OON rates.
• RCW 48.49.030(2) is recognized as a specified state law governing OON reimbursement for emergency and nonemergency services within its scope.
• The federal IDR process under 45 CFR 149.510 and 149.520 applies to services beyond the state law's reach, such as air ambulance services and specific OON cases.

Conclusion

The Washington SBL establishes clear protections against surprise medical billing and sets reimbursement guidelines for OON services. While the state law governs specific emergency and nonemergency services, the federal IDR process provides a complementary framework for cases outside the law's scope, ensuring comprehensive patient protection and equitable resolution of disputes.