Washington Attorney General (AG) Nick Brown announced a settlement with Central Washington Health Services Association, doing business as Confluence Health, over its handling of charity care refunds. The AG alleges that since 2021, thousands of low-income patients at Confluence’s two hospitals made payments toward their hospital bills and were later approved for charity care under Washington’s Charity Care Act, but did not receive refunds of those payments. The act, which was expanded in 2022, requires most Washington hospitals to provide free or discounted care to patients with household incomes up to 400% of the federal poverty level.
To resolve the AG’s allegations without litigation, Confluence entered an assurance of discontinuance in Chelan County Superior Court, agreeing to pay restitution to affected patients and prospective compliance commitments. Confluence did not expressly admit to a violation of the Washington Consumer Protection Act.
Under the assurance of discontinuance, Confluence paid $1,819,885 in restitution to 4,729 patients. This amount represents refunds of patient payments made during the period in which those patients were approved for charity care, plus 12% interest. In addition, Confluence must pay $150,000 to the AG’s office to cover the state’s fees and costs related to the investigation, compliance monitoring, and future enforcement efforts.
Importantly, the assurance expressly identifies as an unfair or deceptive act under the Consumer Protection Act a hospital’s failure to refund all payments made by patients during the time period of their demonstrated approval for charity care. Confluence admits that its practices in some instances varied from its own charity care policy and that it engaged in that practice, but it does not admit that it violated the Consumer Protection Act. Confluence agreed not to engage in the challenged practice going forward. In turn, the state released Confluence from civil claims under the Consumer Protection Act arising out of the described conduct, as long as Confluence complies with the assurance. If Confluence violates the assurance, the release is void, and a violation of the assurance will be prima facie evidence of a Consumer Protection Act violation, allowing the AG to seek an injunction, restitution, civil penalties, and other relief for conduct covered by the assurance, both before and after its execution.
Why It Matters
For hospitals and health systems, this settlement reinforces that Washington regulators are closely scrutinizing not only charity care eligibility determinations, but also how charity care is operationalized through billing, payment, and refund processes. The AG’s position is that providers must affirmatively identify and refund all payments made by patients for services during a period later approved for charity care; it is not sufficient according to the AG, merely to approve charity care prospectively or upon application.
Beyond Washington, the Confluence settlement is another data point in a national trend of regulators, legislators, and advocates scrutinizing hospital financial assistance practices, especially in the context of medical debt. States are increasingly expanding charity care requirements, tying them to nonprofit hospital tax exemption, and using consumer protection theories to challenge billing and collection practices. Actions like this also provide a roadmap for class action plaintiffs’ counsel. As a result, health care organizations — both nonprofit and for‑profit — should anticipate continued pressure to simplify and publicize financial assistance, screen for eligibility earlier and more consistently, and ensure that system design, vendor contracts, and legacy balances do not undermine the protections those laws are intended to provide.
