ASPS, VASPS Fight Inappropriate OON Billing Rules

Since 2018, the Virginia Society of Plastic Surgeons (VASPS) has been working with various stakeholders to negotiate a fair out-of-network solution with the state legislature. ASPS worked closely with VASPS to develop an effective advocacy strategy on the issue and support Virginia plastic surgeons' work toward reaching a compromise. These efforts laid the foundation for continued advocacy on the issue in 2020 and culminated in compromise legislation in March. ASPS and VASPS worked to foster out-of-network legislation that protects patients from unanticipated emergency room care, while still allowing physicians to negotiate adequate reimbursement from health plans.

Background

The product of a years-long effort by key stakeholders, including ASPS and VASPS, the Virginia General Assembly's legislation would stop surprise billing in the state and combat narrow insurance networks, without acting too prescriptively in setting payment rates for out-of-network (OON) care. The lack of concrete parameters was a point of emphasis in ASPS/VASPS communications when the law was passed in March of 2020, with the societies recommending regulations that ensure fair market value for out-of-network services.

Advocacy during implementation

The legislation is currently being implemented by the Virginia Bureau of Insurance (BOI), and given the impact of those rules, ASPS and VASPS were watching their development closely.

When they finally were released, ASPS was deeply concerned by substantive omissions in the BOI regulations relative to state law. ASPS staff undertook substantial analysis and investigative efforts in August and worked closely with VASPS leadership to identify areas of concern and verify that state law supersedes any changes made by BOI regulations.

Specifically, ASPS was alarmed by the removal in the proposed rule of language directing the development of data sets for use in arbitration. The law directed creation of data sets related to median in-network payments, median OON allowed amounts, and median charges, the last of which is very important for demonstrating the true market value of physician services.

A significant focus for ASPS and VASPS in advocating on the issue was outreach to various state agencies in Virginia, as well as communication and coordination with on-the-ground stakeholders. VASPS lobbyist James Pickral helped drive that coordination by establishing a centralized effort to combat the rules, soliciting input and support from key people across healthcare policy community in the state, including the Medical Society of Virginia, the Virginia Hospital & Healthcare Association (VHHA), and state specialty societies.

These parties aggressively lobbied the BOI to amend the proposed rules. ASPS and VASPS submitted comments in early September that questioned the legality of several of the rules' provisions because they substantively change the underlying law. In the letter, the societies asked the BOI to amend its regulations to implement the April 2020 balance billing legislation according to the letter of the law.

The BOI is currently finalizing the regulations. Watch or updates from ASPS on this ongoing issue, which has significant implications for both patients and providers in Virginia.