We continue to work on the issue of surprise billing with the two bills that are left, SB 172 and HB 1251. They are progressing – but in very different formats.
We support the language in SB 172, which does not set a rate in the Code and protects patients while putting the responsibility back on the insurers and providers to work out payment — with arbitration as a backstop. The bill is supported by emergency physicians, the Medical Society of Virginia, physician specialties, hospitals, and patient advocacy groups.
The bills passed their respective houses and are now going through the other house’s committee processes.
As is the custom after crossover, the committees “conform” to similar bills so they look like the ones that passed their house. Now, SB 172 has the language from HB 1251, and HB 1251 has the language of SB 172. The patrons will then reject the amendments, and the bills will be put into a committee of conference where a compromise will be reached – or where both bills will die. We remain cautiously optimistic that a solution will be reached this year that is favorable to patients and physicians.
To that end, we continue to engage in negotiations with insurers and their patrons in the hope of coming to a compromise. Until that happens, we continue to support the arbitration model language.
This bill provides a dispute-resolution process as an alternative way to solve the problem of surprise billing. The goal of this version was to break the stalemate between insurers and healthcare providers and avoid the need for the General Assembly to establish payment rates in statute.
We were able to defeat the insurers' bills that wanted to set out-of-network rates at the lower 125% of Medicare or the in-network rate. However, the insurers do not support SB 172 and will keep trying to get their payment benchmark to be the solution.
Patients will be guaranteed not to be billed for emergency or non-emergency out-of-network claims at an in-network facility.
Doctors and hospitals will only request arbitration if they do not think the “usual and customary payment” is reasonable AND the normal dispute process breaks down. This should not result in a glut of arbitration cases: a Board of Insurance study showed that 0.3% of claims were out-of-network emergency claims in Virginia. That’s a fraction of claims, meaning the number that could end up in arbitration would not be large, even if you add in non-emergencies. In New York, there were less than 1,000 cases a year in a state with a population twice that of the Commonwealth.
It requires arbitration to be completed in 60 days and also allows providers to batch claims together so no one is arbitrating a single claim at a time, which would be administratively burdensome for both parties.
The goal of arbitration is to serve as a powerful backstop, providing a strong incentive for both insurers and providers to set fair payments and prices right from the start.
