New law protecting Virginians against surprise medical billing takes effect on Jan. 1

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Many Virginians will soon be protected against surprise medical billing thanks to a new law that takes effect Jan. 1.

Surprise billing – or balance billing – occurs when patients enrolled in managed care health insurance plans receive bills for more than their plan’s cost-sharing amounts (such as deductibles, coinsurance and co-pays) directly from medical service providers who do not participate in the plan’s network of providers – often referred to as “out-of-network” providers.

The new law protects individuals from balance billing for emergency services, as well as non-emergency laboratory and professional services including surgery, anesthesia, pathology, radiology and hospitalist services.

Starting Jan. 1, individuals enrolled in either fully insured managed care health insurance plans issued in Virginia or the state employee health benefit plan cannot be balance billed successfully by an out-of-network provider for emergency services. Additionally, out-of-network providers cannot balance bill these individuals for certain non-emergency services during a scheduled procedure at an in-network hospital or other health care facility.

Although the new balance billing law does not apply to self-funded group health plans and certain other self-funded plans, those plans may opt in so that the law’s protections apply to their enrollees. These plans are known as elective group health plans. More than 200 elective group health plans have already opted in beginning Jan. 1.

A list of plans that have chosen to opt in is available on the State Corporation Commission Bureau of Insurance website at Search Elective Group Health Plans | Balance Billing (virginia.gov).

Plans that wish to opt into the balance billing protections beginning at a later date can find the application on the Bureau’s website at Virginia SCC – Balance Billing. To opt in, these groups or their third-party administrators must complete and submit an online application at least 30 days before either the beginning of their plan year or Jan. 1 of any subsequent year.

The new law works, in part, by requiring insurers and providers to resolve balance billing disputes – rather than the provider simply sending the consumer a balance billing. When a consumer is treated by an out-of-network health care provider for services covered by the new law, the provider will submit the claim to the consumer’s insurer or health plan.

The insurer or health plan will pay the provider a “commercially reasonable amount” that is based on payments for the same or similar services in a similar geographic area, thereby eliminating any balance payment by the consumer to the provider for services rendered.

If they cannot agree on the amount due, the provider and the insurer or health plan may begin a claims resolution process. As part of that process, the insurer and out-of-network provider must first try to agree on a payment amount. If they cannot agree, one of the parties may request that an arbitrator determine the final payment amount and resolve disputes.

Arbitrators must report their final decision to both arbitrating parties and to the Bureau using the Arbitrator Decision Reporting Form, which is available on the Bureau’s website at Virginia SCC – Balance Billing.

The Bureau is currently accepting applications for individuals interested in serving as arbitrators for balance billing disputes. Arbitrators should have training and experience in arbitration or dispute resolution and matters related to medical or health care services.

For more information, including an application and a list of approved arbitrators, visit Virginia SCC – Balance Billing.

Additionally, the new law requires health care facilities and medical providers to notify consumers about balance billing protection for out-of-network services. Among other things, these notifications must inform consumers how to determine if they are protected from surprise billing, when they can be balance billed, and what to do if they are billed too much.

Providers must notify consumers (on their websites or otherwise) about which networks they participate in; refund to consumers any overpaid amounts within 30 business days; provide to consumers a notice of their rights under the balance billing law, and refrain from asking consumers to limit or give up their rights under the balance billing law.

Managed care health insurance plans regulated by the Bureau also must notify enrollees regarding if and when they are subject to balance billing, as well as notify enrollees of their rights under the new law. If an enrollee is subject to balance billing, the new law requires that their financial responsibility must be based on what they would pay an in-network provider or in-network facility in their area.

If health care providers have a pattern of violations under the new law without attempting corrective action, they are subject to fines or other measures by the Virginia Board of Medicine or the Virginia Commissioner of Health. Similarly, insurance companies that are found to engage in a pattern of violations of the new law are subject to fines or other sanctions by the SCC.

For more information, contact the Virginia Bureau of Insurance toll-free at 1-877-310-6560 or visit scc.virginia.gov. Questions related to the arbitrator application, requests to arbitrate, or questions regarding the self-funded opt-in process may be emailed to BBVA@scc.virginia.gov.

Consumer questions and complaints about balance billing may be emailed to BureauofInsurance@scc.virginia.gov.


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