surprise billing and dataset presentation...balance billing protection act. 5. starting january 1,...
TRANSCRIPT
Surprise Billing Dataset Review
October 9, 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
4
• Chapter 48.49 RCW
• Chap. 427, Laws of 2019/2SHB 1065
• Proposed rules filed on October 2, 2019
Balance Billing Protection Act
5
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
6
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.
Balance Billing Protection Act
7
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
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
13
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
14
15
Geographic Rating Regions
Overview of Surprise Billing Dataset
16
Questions?
17