The Balance Billing law covers emergency care, laboratory services, and any professional nonemergency services, including:
- Surgery
- Anesthesia
- Pathology
- Radiology
- Hospitalist services
If a consumer is treated by an out-of-network provider or facility for services covered by the new Balance Billing law, the provider or facility will submit the claim to the patient’s insurer. The insurer will pay a “commercially reasonable amount” based on payments for the same or similar services in a similar geographic area.
If the provider or facility and insurer don't agree to what is a commercially reasonable amount, then an arbitration process is available to resolve disputes. See list of approved insurers.
Balance Billing Protection for Out-of-Network Services
Starting January 1, 2021, Virginia state law may protect you from “balance billing” when you get:
- Emergency services from an out-of-network hospital, or an out-of-network doctor or other medical provider at a hospital
- Non-emergency surgical or ancillary services from an out-of-network lab or health care professional at an in-network hospital, ambulatory surgical center, or other health care facility.
Balance Billing Law FAQs
What is balance billing (also called "surprise billing")?
You can't always control who you get your healthcare from. Balance billing, also called surprise billing, happens when you see a doctor or use a healthcare service that isn’t part of your health insurance plan’s network. When that happens, you may have to pay the difference between what your insurance covers and the full cost of the service.
Using services that aren't in your insurer's network can make the bill much higher.
How do surprise bills happen?
Surprise bills can happen when you can’t choose your doctor, like in an emergency. It can also happen when an in-network hospital has out-of-network specialists. You might think your care is covered in-network, but then get billed more because some providers were out-of-network.
How can I see if I'm protected?
Check with you insurer about your plan.
Who is protected by Virginia’s balance billing law?
Virginia law protects people with health plans that are fully-insured in Virginia, state employee health plans, and some self-funded groups that choose to follow Virginia’s protections.
What should I do if I think I was wrongly billed?
You can call 800.985.3059 for federal help or file a complaint with the Virginia State Corporation Commission at 877.310.6560 or visit their website.
See more about balance billing (PDF).