RICHMOND, Va. (CBS19 NEWS) -- A new law will soon be going into effect that could help protect people from surprise medical bills.
According to a release from the State Corporation Commission, surprise or balance billing can happen when patients enrolled in managed health insurance plans get bills for more than their plan's cost-sharing amounts, such as deductibles and co-pays, from medical service providers who do not participate in the plan's network of providers.
Under the new law, such people will be protected from balance billing from out-of-network providers for emergency services, as well as non-emergency laboratory and professional services such as surgery, anesthesia, pathology, and radiology.
Beginning on Jan. 1, people who are enrolled in either fully insured managed health care plans issued in Virginia or state employee health benefit plans cannot be balance billed by an out-of-network provider for emergency services.
The release says such providers also cannot balance bill these people for certain non-emergency services that occur during a scheduled procedure at an in-network hospital or other health care facility.
This does not apply to self-funded group health plans also called elective group health plans and certain other self-funded plans, though those plans may opt-in so that the protections will apply to enrollees.
SCC says more than 200 such elective group health plans have already opted in, which will go into effect on Jan. 1.
Plans that have not yet opted in for the protections can still apply, but the protections will begin at a later date. To do so, the groups or their third-party administrators will need to complete an online application at least 30 days before either the beginning of their plan year or Jan. 1 of any subsequent year.
The release says the law works by requiring insurers and providers to resolve balance billing disputes rather than simply sending the consumer a bill.
Should a patient get treatment from an out-of-network provider for a service covered by the new law, that provider will have to submit the claim to the patient's insurer or health plan. The insurer or plan will then have to pay the providers a "commercially reasonable amount" based on payments for the same or similar services in a similar geographic area, which will eliminate any balance payment.
The release adds that if the provider and insurer cannot agree on the amount due, they may begin a claims resolution process, through which one of the parties can ask for an arbitrator to determine the final payment amount and resolve the dispute. Arbitrators will report their final decision to both parties and to the State Corporation Commission.
The SCC's Bureau of Insurance is also accepting applications for people who would be interested in serving as arbitrators for these kinds of disputes. Applicants should have training and experience in arbitration or dispute resolution and matter related to medical or health care services.
The release adds that the new law also requires health care facilities and medical providers to notify consumers about balance billing protection for out-of-network services, and such notifications need to tell 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.
Additionally, providers need to notify consumers about which networks they participate in, refund overpaid amounts within 30 business days, provide a notice of rights under the balance billing law to consumers, and not ask consumers to limit or give up their rights under this law.
Enrollees in managed care health insurance plans that are regulated by the SCC will also have to be notified about if and when they may be subject to balance billing and of their rights under this law. The law requires that the financial responsibility of the consumer be based on what the consumer would pay an in-network provider or in-network facility in their area.
Health care providers who demonstrate a pattern of violation of this law without trying to fix the issue will be subject to fines or other measures by the Virginia Board of Medicine or the Virginia Commissioner of Health. Insurers may also be subject to fines or other sanctions by the SCC.
For more information or to apply to be an arbitrator, click here. Questions about applying to be an arbitrator or the self-funded opt-in process can be emails to bbva@scc.virginia.gov. Consumer questions and complaints about balance billing can be sent to bureauofinsurance@scc.virginia.gov.