April 16, 2020

Out-of-Network-Legislation Signed into Law in Virginia

Virginia Gov. Ralph Northam signed House Bill 1251 into law on April 10, 2020.

Provisions of the bill include a ban on balance billing from out-of-network providers for emergency or non-emergency services provided to an enrollee at an in-network facility if the nonemergency services involve surgical or ancillary services. The statute’s definition of "surgical or ancillary services" includes surgery, anesthesiology, pathology, radiology or hospitalist services and laboratory services.

The statute calls for the insurance carrier to pay “a commercially reasonable amount, based on payments for the same or similar services provided in a similar geographic area.”

The State Corporation Commission is mandated to contract with a nonprofit, data services organization to establish a data set and business process to provide health carriers, health care providers, and arbitrators with data to assist in determining commercially reasonable payments and resolving payment disputes for out-of-network medical services rendered by health care providers.

The claim must be paid within 30 calendar days of receipt of a clean claim from an out-of-network provider. The out-of-network provider may dispute the received amount no later than 30 calendar days after receipt of payment or payment notification from the carrier.

If a dispute occurs, the carrier and provider shall have 30 calendar days from the initial offer to negotiate in good faith. If unable to agree on a commercially reasonable payment amount within 30 calendar days, either party may choose to pursue arbitration (as provided in Section 38.2-3445.02). The parties are permitted to bundle claims for arbitration if the claims at issue involve identical carrier and provider parties, involve claims with the same or related current procedural terminology codes relevant to a particular procedure, and occur within a period of two months of one another.

The provisions of the law outlined above will go into effect on Jan. 1, 2021.