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? 2

Balance Billing Protection Act 3

Balance Billing Protection Act • Chapter 48.49 RCW • Chap. 427, Laws of 2019/2SHB 1065 • Proposed rules filed on October 2, 2019 4

Balance Billing Protection Act 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. 5

Balance Billing Protection Act 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 out-of-network provider. • No provider, hospital or outpatient surgical facility can ask a patient to limit or give up these rights. 6

Balance Billing Protection Act 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. 7

Surprise Billing Dataset 8

Second Substitute House Bill 1065, Section 26 9

Second Substitute House Bill 1065, Section 26 10

Second Substitute House Bill 1065, Section 26 11

Second Substitute House Bill 1065, Section 6 12

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 13

Surprise Billing Specifications 14

Geographic Rating Regions 15

Overview of Surprise Billing Dataset 16

Questions? 17