RD64 - Report of the Virginia Balance Billing Work Group – December 31, 2019

Executive Summary:

*This report was replaced in its entirety by the Secretary of Health and Human Resources on January 23, 2020.

The purpose of this report is to provide an analysis and present findings from the Virginia Balance Billing Workgroup to address the practice of balance billing. The Secretary of Health and Human Resources, as directed by the General Assembly established this Workgroup pursuant to the 2019 Appropriation Act, Item 281 F, which states:

The Secretary of Health and Human Resources, in collaboration with the Secretary of Administration, Secretary of Finance, and State Corporation Commission (SCC), shall convene a workgroup to evaluate options to prohibit the practice of balance billing by out-of-network health care providers for emergency services rendered, and to establish equitable and fair reimbursement for these health care providers. The workgroup shall include: 1) staff from the House Appropriations and Senate Finance Committees and representatives from such state agencies as the Commission and Secretaries deem appropriate, and 2) relevant stakeholders, including but not limited to, the Medical Society of Virginia, Virginia College of Emergency Physicians, Virginia Hospital and Healthcare Association, Virginia Association of Health Plans, Virginia Poverty Law Center, and National Patient Advocate Foundation. The workgroup shall include in its report the fiscal impact of each option considered and the impact on provider networks. The workgroup also shall include in its report recommendations for future legislation for consideration by the General Assembly. The SCC shall provide analytical and actuarial services pursuant to the workgroup's analysis and development of a proposal, as needed. The workgroup shall protect any proprietary and confidential data of any health plan, healthcare provider, or third party administrator in its final report. The workgroup shall report its recommendations to the Governor and the Chairmen of the House Appropriations and Senate Finance Committees by November 15, 2019.

The Balance Billing Workgroup, or Workgroup, was composed of a diverse group of stakeholders, including members from the following state agencies, organizations, and groups:



Commissioner of Insurance and other representatives of the Bureau of Insurance

Department of Human Resource Management

Department of Medical Assistance Services

Hospital Corporation of America

House Appropriations Committee

Joint Commission on Health Care

Medical Society of Virginia

National Patient Advocate Foundation

Office of the Secretary of Administration

Office of the Secretary of Finance

Office of the Secretary of Health and Human Resources

Senate Finance Committee


Virginia Association of Health Plans

Virginia College of Emergency Physicians

Virginia Commonwealth University

Virginia Hospital and Healthcare Association

Virginia Poverty Law Center

Virginia Society of Anesthesiologists

Virginia Society of Plastic Surgeons

Williams Mullen

Various representatives from related industries including insurance carriers, physician member organizations and patient advocates attended meetings and contributed to the discussions.

The Workgroup first met on August 28, 2019 and then on September 18, 2019. Secretary of Health and Human Resources Daniel Carey, MD and Deputy Secretary of Health and Human Resources Marvin Figueroa lead the meetings. Notes were taken during each meeting and subsequently provided to the members. In the first meeting, the Workgroup examined the federal landscape of balance billing and payment standard options. Representatives from the National Governor's Association National Center for Best Practices and Georgetown University facilitated the discussion. The second meeting examined the 2019 Session proposed balance billing legislation and the impact on state plans. The Workgroup asked that three policy options be analyzed by the Department of Human Resource Management (DHRM) and the Bureau of Insurance (BOI) including the provisions in HB 1714 (2019), HB (2544) or a singular payment standard that does not fall below 200% of Medicare. The Workgroup did not reach consensus for a specific recommendation.