Final Order — Reimbursement Violations under Oregon Surprise Balance Billing Rules
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Final order addressing Regence BlueCross BlueShield of Oregon's reimbursement of out-of-network providers at rates inconsistent with Oregon SBB rules; affects the insurer and providers/payors subject to Oregon insurance law.
No material clinical or coverage changes in this revision.
Orders and Findings
Orders and Findings
Enforcement actions and requirements imposed on the Respondent:
ALL of the following
- Respondent reimbursed out-of-network providers for services subject to the SBB Rules at rates different from those mandated by the Oregon Administrative Rules (violations occurred in 117 instances).
Findings of fact and conclusions of law.
- Director orders Respondent to CEASE AND DESIST from violating ORS 743B.287(3) and (6).
Authority: ORS 731.252(1).
- Director imposes a CIVIL PENALTY of $30,000 on Respondent for violating ORS 743B.287(3) and (6) in 117 instances.
Authority: ORS 731.988(1).
Reimbursement Mandates (Surprise Balance Billing Rules)
Reimburse out-of-network care at SBB‑mandated rates
Oregon’s SBB Rules (OAR 836-053-1600 through 836-053-1615) require payors to reimburse out-of-network services provided at in-network facilities at the particular rates mandated by those rules to mitigate the economic burden of surprise balance billing on patients.
Key Terms and Rules
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