Surprise Billing Surprise Billing Dataset Review Dataset Review - - PowerPoint PPT Presentation

Surprise Billing Surprise Billing Dataset Review Dataset Review

October 9, October 9, 2019 2019

Agenda

• Balance Billing Protection Act - Overview

Jane Beyer, OIC

• Surprise Billing Dataset – Statutory requirements

Thea Mounts, OFM

• Surprise Billing Dataset - Specifications

Onpoint Health Data

• Surprise Billing Dataset – Overview

Onpoint Health Data

• Questions?

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Balance Billing Protection Act

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Balance Billing Protection Act

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• Chapter 48.49 RCW
• Chap. 427, Laws of 2019/2SHB 1065
• Proposed rules filed on October 2, 2019

Balance Billing Protection Act

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Starting January 1, 2020 surprise billing is prohibited for:

• Emergency services, and
• Non-emergency inpatient and outpatient ‘surgical and ancillary services’ provided by

an out-of-network provider at an in-network hospital or outpatient surgical center.

• ‘Surgical and ancillary services’ include: surgery, anesthesiology, pathology, radiology,

laboratory and hospitalist services.

Balance Billing Protection Act

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When surprise billing is not allowed, the following protections also apply:

• Insurers must pay out-of-network providers and facilities directly.
• Cost-sharing must be based on what an in-network provider would be paid, and the

explanation of benefits must show how much is the patient’s responsibility.

• Any amount the patient pays must be applied to their deductible and out-of-pocket

limit.

• A provider must refund, within 30 business days, any amount the patient overpaid an
• ut-of-network provider.
• No provider, hospital or outpatient surgical facility can ask a patient to limit or give up

these rights.

Balance Billing Protection Act

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Who does the Act apply to?

• Fully-insured health plans sold in Washington state (as defined in RCW 48.43.005) –

Includes plans sold through the Exchange

• Washington state employee health plan (PEBB) and new Washington state school

employee health plan (SEBB)

• Self-funded group health plans that ‘opt-in’ to certain parts of the Act.

Surprise Billing Dataset

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Second Substitute House Bill 1065, Section 26

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Second Substitute House Bill 1065, Section 26

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Second Substitute House Bill 1065, Section 26

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Second Substitute House Bill 1065, Section 6

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Summary of Key Components

• The data set must provide the amounts for these services:
• Emergency services
• Nonemergency services provided at an in-network hospital or in-network ambulatory surgical

facility if the services (a) involve surgical or ancillary services and (b) are provided by out-of- network providers.

• Most recently available full calendar year of data
• Commercial fee-for-service data, excludes Medicaid and Medicare
• Median in-network and out-of-network allowed amounts, and median billed charges
• By geographic area
• Update annually using CPI-M

Surprise Billing Specifications

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Geographic Rating Regions

Overview of Surprise Billing Dataset

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Questions?

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