SB 243

Abstract

Balance billing; emergency services. Provides that when a covered person receives covered emergency services from an out-of-network health care provider, the covered person is not required to pay the out-of-network provider any amount other than the applicable cost-sharing requirement. The measure deletes a provision that allows an out-of-network provider to charge an individual for the balance of the provider's billed amount after applying the amount the health carrier is required to pay for such services. The measure also establishes a fourth standard for calculating the health carrier's required payment to the out-of-network provider of the emergency services, which standard is (i) the regional average for commercial payments for such service if the provider is a health care professional or (ii) the fair market value for such services if the provider is a facility. This fourth standard is the amount the health carrier is obligated to pay to the out-of-network provider if the amount is greater than any of the other three standards, which are (a) the amount negotiated with in-network providers for the emergency service or, if more than one amount is negotiated, the median of these amounts; (b) the amount for the emergency service calculated using the same method the health carrier generally uses to determine payments for out-of-network services, such as the usual, customary, and reasonable amount; or (c) the amount that would be paid under Medicare for the emergency service. The measure requires the health carrier to pay the required amount, less applicable cost-sharing requirements, directly to the out-of-network health care provider of the emergency services. If such provider determines that the amount to be paid by the health carrier does not comply with the applicable requirements, the measure requires the provider and the health carrier to make a good faith effort to reach a resolution on the appropriate amount of the reimbursement and, if a resolution is not reached, authorizes either party to request the State Corporation Commission to review the disputed reimbursement amount and determine if the amount complies with applicable requirements. The measure also provides that final diagnosis rendered to a covered person who receives emergency services for a medical condition shall not be considered in the health carrier's determination of whether the medical condition was an emergency medical condition. The measure establishes the procedure by which the regional average for commercial payments for emergency services will be calculated by the nonprofit data services organization that compiles the Virginia All-Payer Claims Database. The measure also requires health carriers to makes reports to the Bureau of Insurance and directs the Bureau to provide reports to certain committees of the General Assembly.