CODE OF VIRGINIA

PAYMENT AND REIMBURSEMENT PRACTICES; PROHIBITIONS (§ 65.2-821.1)

A. As used in this section, unless the context requires a different
meaning:”Contracting entity” means (i) a person that enters into a
provider contract with a provider or (ii) an intended beneficiary of the rights
of such person under the provider contract.”Employer” means the
employer; any insurance carrier, group self-insured association, or other person
providing coverage for the employer’s obligation to provide medical
service to a claimant under this title; or any third-party administrator acting
on behalf of the employer.”PPO network” means the multiple provider
contracts available to an employer pursuant to a PPO network
arrangement.”PPO network arrangement” means an arrangement under
which the PPO network arranger sells, conveys, or otherwise transfers to an
employer the ability to discount payments or reimbursements to a provider
pursuant to the terms of multiple provider contracts to which the PPO network
arranger is a direct party.”PPO network arranger” means a person
that operates a PPO network arrangement.”Provider,”
“transition date,” and “Virginia fee schedule” have the
meaning assigned thereto in § 65.2-605. “Provider” includes a
provider’s employer or professional business entity.”Provider
contract” means an agreement between a contracting entity and a provider
pursuant to which the provider agrees to deliver medical services to a claimant
under this title in exchange for payment or reimbursement of an agreed-upon
amount.”Third-party administrator” means a person that administers,
processes, handles, or pays claims to providers on behalf of an employer.

B. On and after the transition date:

   1.  No employer shall pay or reimburse a provider for medical services
   provided to a claimant less than the amount provided for in the applicable
   Virginia fee schedule or other amount determined as provided in subdivision B
   2 or 3 of § 65.2-605 unless:
               
            

      a.  The employer has directly entered into:
                     
                     
                  

         (1.  A provider contract with the provider;

         (2.  A contract with a contracting entity that has entered into a provider
         contract with the provider; or

         (3.  A contract with a PPO network arranger that authorizes the employer
         to use a PPO network to derive a benefit from a provider contract; and

      b.  The provider has agreed to provide medical services to the claimant for
      an agreed-upon reimbursement or contractual amount as set forth in a
      provider contract referenced in subdivision a.

   2.  A person with whom an employer has directly contracted as described in
   subdivision 1 a shall not sell, lease, or otherwise disseminate data regarding
   the payment or reimbursement amounts or terms of a provider contract without
   the express written consent and prior notification of all parties to the
   provider contract; however, the express written request from, and prior
   notification to, a provider shall not be required if the provider’s
   identity has been redacted from such data.

   3.  If an employer uses or relies on a contract described in subdivision 1 a
   to discount a payment or reimbursement to a provider, the employer shall
   notify the provider, at the time it remits the payment or reimbursement, of
   (i) the name of the provider, contracting entity, or PPO network arranger with
   whom the employer directly contracted and (ii) how, if other than by a direct
   contract between the employer and the provider, the employer acquired the
   right to discount the payment or reimbursement to the provider.

   4.  If an employer uses or relies on a contract with a PPO network arranger
   described in subdivision 1 a (3) to discount a payment or reimbursement to a
   provider, the employer shall not shop for the lowest discount for a specific
   provider among the provider contracts held in multiple PPO networks. This
   prohibition shall not bar an employer that has entered into a PPO network
   arrangement and selected a provider contract in the PPO network from availing
   itself of all discounts provided pursuant to the selected provider contract in
   the PPO network.

C. Any person who suffers loss as a result of a violation of this section shall
be entitled to initiate an action at the Commission to recover actual damages
and interest from the date of the violation until entry of the final award. If
the Commission finds that the violation resulted from gross negligence or
willful misconduct, it may increase damages to an amount not to exceed three
times the actual damages.

HISTORY: 2016, cc. 279, 290.