November 2019 - Onpoint’s APCD and reporting client, the state of Washington, recently enacted the Balance Billing Protection Act, which will become effective on January 1, 2020. The Act aims to protect consumers from balance (or “surprise”) bills – specifically for out-of-network facility or provider charges billed to patients for emergency services or for certain non-emergency services that patients receive at in-network hospitals or ambulatory surgical facilities.
Under this law, if a patient is treated by an out-of-network provider or facility for services covered by the law (e.g., emergency services and non-emergency anesthesia, laboratory, pathology, radiology, surgery, and hospitalist services provided at an in-network hospital or ambulatory surgical facility), the provider or facility will submit the claim to the patient’s insurer. The provider or facility will then be paid a commercially reasonable amount based on payments for the same or similar services in a similar geographic area. The insurer and the facility or provider must first try to agree on this amount. If an agreement is not reached, the dispute is settled through arbitration facilitated by a third-party arbitrator.
A Surprise Billing Data Set, which includes payment data for services subject to the Act, will be available as a tool to assist in settling payment disputes. In collaboration with Onpoint, the State has developed this data set from the Washington All-Payer Health Care Claims Database (WA-APCD). This new data set includes commercial fee-for-service data from the WA-APCD and was prepared by Onpoint in consultation with a workgroup led by the state that included representatives from key stakeholder groups, including medical providers, hospitals, ambulatory surgical centers, and carriers. The Surprise Billing Data Set will provide payment data for services subject to the Balance Billing Protection Act and will be available to assist insurers, facilities, providers, and arbitrators as an independent source of claims payment information.
“We greatly appreciate the extensive time and effort that Onpoint has put into development of the data set,” says Jane Beyer, Senior Health Policy Advisor at the Washington State Office of the Insurance Commissioner (OIC). (See below for screen shots from the OIC’s introductory video to the balance billing Act, available on their website.)
Onpoint’s team is excited to support this important policy initiative, which is part of the state’s broader effort to make healthcare more affordable, fair, and transparent for patients in Washington.
Informational Video (Screen Grabs) of Balance Billing Act
- On-Pointers: Best Billing Practices for APCD Claims Data
- Exploring the Differences Between Commercial & Medicaid/Medicare Data Sources
- Understanding Your Enhanced Summary Tables: Inpatient Stay Summary & Medical Claim Header
- Onpoint Begins Work on Next-Generation APCD with the State of Vermont, Green Mountain Care Board