American Society of Plastic Surgeons
For Consumers

ASPS Supports VASPS's Out-of-Network Lobbying Efforts

Since 2018, the Virginia Society of Plastic Surgeons (VASPS) has been working with other stakeholders to negotiate a fair out-of-network solution with the state legislature. Last year, the house of medicine was optimistic that it would be able to strike a deal that would protect patients from unanticipated emergency room care while still allowing physicians to negotiate adequate reimbursement from the health plans. ASPS also worked with the Virginia Society of Plastic Surgeons (VASPS) to support fast-moving out-of-network legislation. That bill broke down ultimately, as carriers were unwilling to meet the physicians and patients halfway.

Fast forward to this year, and the situation in Virginia remained unclear. Patients, physicians and insurers failed to find an acceptable solution early on in the legislative session. However, things evolved at a more rapid pace in February, during which Virginia legislators began to favor a package similar to the bill that was passed in Washington state in 2019. Following weeks of negotiations – which VASPS was involved in – the final bill was passed by both houses and sent to Governor Ralph Northam (who is a physician). The legislation includes provisions that will rectify the current issues with out-of-network billing, such as requiring insurers to pay physicians directly, creating additional network adequacy determinations for facility-based surgical and ancillary services, implementing network participation notification provisions for facilities and insurers and ensuring that charge-based criteria are among the factors that must be reviewed during dispute resolution.

The main drawback of the measure is that the initial reimbursement is somewhat nebulous, as the definition of "commercially reasonable amount" (the initial payment standard) is not laid out in the bill. With that in mind, ASPS and VASPS contacted Gov. Northam to express their cautious optimism that the commonwealth will get things right.