Starting January 1, 2021, Virginia adopted new laws and rules for “balance billing”.
Duties of Healthcare Provider:
If the health plan’s enrollee is treated by an out-of-network provider for emergency services or an in-network facility for scheduled services covered by Virginia law and rules, the provider or facility that is out of net work will submit the claim to the enrollee’s health plan. The amount the health insurer pays the facility or provider must be “commercially reasonable amount based on the same or similar services in a similar geographic area. If the health care provider and plan cannot agree on the amount, either party can start the arbitration process.
The Virginia of Department of Health provides a data set of what is a commercially reasonable payment data and Protocols.
If health care providers have a pattern of violations under the new law without attempting corrective action, they are subject to fines or other remedies by the Virginia Board of Medicine or the Virginia Commissioner of Health. Similarly, insurance companies that are found to engage in a pattern of violations of the new law are subject to fines or other remedies by the SCC. Neither insurance companies nor health care providers may use arbitration as a general business practice for resolving claims payments.
Right of patient:
A patient has a right to be informed if the provided is in-network or out-of-network before being treated. And the conditions when they can and cannot be balanced bill.
Not all health care providers are subject to this law. However, when a patient schedules a medical service, they should ask their health care provider if they are in-network. Insurers are required to tell them that (on their websites or on request). Hospitals and other health care providers also must tell you (on their websites or on request) which insurance plans they contract with as in-network providers.
When a patient receives an explanation of billing (EOB) it must state what they must pay. If they have a high deductible, they must pay the balance up to their deductible. If there is a dispute, the patient may file a complaint with the Virginia State Corporation Commission, Bureau of Insurance.
Classification and Exemptions of Administrative Workers under FLSA
Misclassification of a worker can carry serious consequences to an employer. In an opinion letter, dated January 8, 2021, the Secretary of Labor considered whether account managers are exempt from the minimum wage and overtime rules under the Fair Labor Standards Act (FLSA) and Portal to Portal Act. As with all FLSA questions, the answer mostly depends of the facts. In this case the facts were the account managers were given flexibility and autonomy to develop account plans and explaining how the product will benefit a prospective client and follow through helping client develop a plan. The account managers are paid above the weekly salary threshold. They perform non-manual work and primarily office work. They exercise discretion and independent judgement with respect to matters of significance. The Director of WHD held they were exempt as administrative employees.
Duties of Healthcare Provider:
If the health plan’s enrollee is treated by an out-of-network provider for emergency services or an in-network facility for scheduled services covered by Virginia law and rules, the provider or facility that is out of net work will submit the claim to the enrollee’s health plan. The amount the health insurer pays the facility or provider must be “commercially reasonable amount based on the same or similar services in a similar geographic area. If the health care provider and plan cannot agree on the amount, either party can start the arbitration process.
The Virginia of Department of Health provides a data set of what is a commercially reasonable payment data and Protocols.
If health care providers have a pattern of violations under the new law without attempting corrective action, they are subject to fines or other remedies by the Virginia Board of Medicine or the Virginia Commissioner of Health. Similarly, insurance companies that are found to engage in a pattern of violations of the new law are subject to fines or other remedies by the SCC. Neither insurance companies nor health care providers may use arbitration as a general business practice for resolving claims payments.
Right of patient:
A patient has a right to be informed if the provided is in-network or out-of-network before being treated. And the conditions when they can and cannot be balanced bill.
Not all health care providers are subject to this law. However, when a patient schedules a medical service, they should ask their health care provider if they are in-network. Insurers are required to tell them that (on their websites or on request). Hospitals and other health care providers also must tell you (on their websites or on request) which insurance plans they contract with as in-network providers.
When a patient receives an explanation of billing (EOB) it must state what they must pay. If they have a high deductible, they must pay the balance up to their deductible. If there is a dispute, the patient may file a complaint with the Virginia State Corporation Commission, Bureau of Insurance.
Classification and Exemptions of Administrative Workers under FLSA
Misclassification of a worker can carry serious consequences to an employer. In an opinion letter, dated January 8, 2021, the Secretary of Labor considered whether account managers are exempt from the minimum wage and overtime rules under the Fair Labor Standards Act (FLSA) and Portal to Portal Act. As with all FLSA questions, the answer mostly depends of the facts. In this case the facts were the account managers were given flexibility and autonomy to develop account plans and explaining how the product will benefit a prospective client and follow through helping client develop a plan. The account managers are paid above the weekly salary threshold. They perform non-manual work and primarily office work. They exercise discretion and independent judgement with respect to matters of significance. The Director of WHD held they were exempt as administrative employees.
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