December 01, 2020

States Consider Regulations on Out-of-Network Billing

The insurance department of New Mexico will hold a hearing on proposed out-of-network billing rules while Virginia’s issues a final regulation modifying its out-of-network billing rules.

In New Mexico, the Office of the Superintendent of Insurance will hold a hearing regarding the adoption of surprise billing rules on Dec. 28, 2020 at 1pm MST. The proposed rules will implement consumer protection, reimbursement, refund, reporting and appeal requirements from the state’s Surprise Billing Protection Act passed in January 2020.

In Virginia, the Bureau of Insurance has issued a final regulation that would establish requirements and processes to protect consumers from surprise balance billing from out-of-network providers for emergency healthcare services or elective ancillary and surgical services received at an in-network facility, including procedures for the use of arbitration between health carriers and out-of-network providers to address reimbursement disputes concerning balance billing.

As a result of comments received during its public comment period and additional review, the following revisions have been made to the proposed new rules:

  • The definition of "arbitrator" has been revised to allow only individuals, not entities, to apply as an arbitrator;
  • The definition of "clean claim" has been revised to remove the timeframe requirement to file a claim;
  • The definition of "geographic area" has been removed to allow carriers, providers and arbitrators more flexibility in resolving balance billing disputes; and
  • The definitions of "self-funded group health plan" and "group health plan" have been removed and replaced with "elective group health plan" to avoid confusion about the types of group health plans that may opt-in to the balance billing requirements.

The revised regulation will be effective Jan. 1, 2021.