Title of Proposal:

Ending Surprise Billing/Providing Fair Payment for Out-of-Network Physicians

On behalf of:


Describe the Idea or Issue:

Surprise coverage gaps are created by insurance carriers narrowing networks, a lack of transparency in pricing and costs, and a proliferation of high deductible plans that offer affordable premiums, but often leave patients underinsured. Our intent is to draft a comprehensive solution that benefits patients and physicians by banning surprise billing or ‘balance billing’ if a doctor is out of network, if they agree to receive a fair payment that is determined by using a neutral database and reimbursement schedule. Specifically, we believe such a comprehensive solution should include: - Require that surprise billing be banned if the OON physician accepts a fair payment; - Require that insurers pay the providers directly, not the patient. - Create a payment structure that establishes a reimbursement schedule at the 80th percentile of clinician Usual and Customary Charges (UCC), maintained by an independent non-profit not affiliated, financially supported and/or otherwise supported by an insurance carrier. - Create penalties for non-compliance by insures or providers

Desired Outcome:

VACEP, in coordination with the Virginia Academy of Family Physicians, VA Society of Anesthesiologists, VA Orthopaedic Society, VA Society of Eye Physicians and Surgeons, American College of Radiology- VA Chapter, VA Society of Plastic Surgeons, the American Academy of Pediatrics, VA Chapter, and the VHHA, will be introducing legislation in the 2019 session and would like the Medical Society to be an active member of the coalition and make this a top issue on their 2019 Legislative Agenda.



I'm in favor of taking care of patients at a fair rate. The rationale of thisproposal  seems to suggest that "fair" is actually much lower than "usual and customary." Accepting lower than your usual rate to assure guaranteed "to the provider" (rather than easily redirected "to the patient") payments sounds a lot like being "in network" to me, with another layer of bureaucracy added for supervision and enforcement.

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