PORT ANGELES — After Oct. 1, patients seen at the emergency room at Olympic Medical Center will receive two bills following their visit.
One bill will be from OMC facility services and the other will be from the emergency department service provider Sound Physicians.
Sound Physicians took over for Peninsula Emergency Services Inc. (PESI) in the emergency department when OMC ended its contract with PESI, a physician-led company, in June.
The contract with Sound Physicians will be finalized on Oct. 1, when OMC says the Seattle-based company will fully take over providing emergency room doctors.
This two-bill system is not uncommon in healthcare, according to Joanna Weber, director of Revenue Cycle Management at OMC.
“In a normal model, when you have a private group like Sound Physicians, they do their own billing,” Weber said. “Peninsula Emergency Services did not have the infrastructure to do its own billing, so we were a little bit different in that we agreed to take on that piece.”
Sound Physicians doing its own billing means it has its own contracts with health insurance providers. The Sound Physicians providers are fewer than those with OMC contracts.
But that won’t affect the amounts of the emergency services bill, due to the federal No Surprises Act, which came into effect on Jan. 1.
It ensures that no out-of-network provider is allowed to balance bill a patient for an amount more than their current in-network co-pay/cost-share.
“The No Surprises Act really protects all patients for services provided in the emergency room,” Weber said.
“What it says is that facilities and providers, so hospitals and doctors cannot collect from a patient more than their networks cost-sharing amount for out-of-network emergency services.”
Sound Physicians accepts insurance from United Health Care (Commercial and Medicare Advantage), United Health Care Community Care, CIGNA, and Tri-Care and is in the process of contracting to be an in-network provider with Coordinated Care, Community Health Plan of Washington (Apple Health), Amerigroup, Molina and Kaiser.
OMC accepts insurance from Amerigroup, Aetna, CIGNA, Community Health Plan of Washington State (Apple Health), First Choice, Premera, Medicare, Medicaid, Molina, Regence, Tri-Care, Uniform Medical, United Health Care and Veterans Affairs.
Premera customers, which include OMC employees, recently received a startling letter from the insurance provider informing them that, effective July 1, when the transition from PESI to Sound Physicians occurred, their insurance would be out considered of network.
OMC Board President John Nutter said there were several inaccuracies in the letter from Premera, and OMC was working to clarify the confusion it caused.
“The information sent out by Premera is not correct and has caused significant unwarranted concern. Internal communications are being distributed to correct the misinformation, and it’s unfortunate that any of this occurred,” Nutter said.
“OMC has been contracted with Premera for decades, and any separate physician billing would be required to be done under contract as well. All physician groups at OMC (radiologists, pathologists, anesthesiologists and potentially the ER group) have standard contract language that requires them to accept the same insurance contracts that OMC does.
“Adding to the confusion is the fact that OMC is doing the physician billing the same way today as we have for as long as I can remember. Nothing has changed, yet Premera sent out that letter for reasons I don’t yet understand, ” Nutter said.
The No Surprises Act protects emergency medical services.
“The other impact is for non-emergency services, and this is where it can get confusing, by nonparticipating providers performing services in a participating facility,” Weber said.
“For example, if you are going to have surgery at OMC and we are contracted with your insurance but your surgeon is not contracted with your insurance, they can’t bill you for more than what your in-network rate for that surgery would be,” Weber explained.
Washington State’s Balance Billing Protection Act, which went into effect in 2020, essentially provides similar protection, preventing patients who receive emergency care at any medical facility from getting a surprise bill because the facility was out of network.
The state plans to adopt the federal guidelines in July 2023, making the process simpler.
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Reporter Ken Park can be reached at [email protected].
