Virginia SCC – Balance Billing

The data set was created in consultation with a work group that included representatives of medical providers, hospitals and insurers, and reviewed by the advisory committee that oversees the operation of Virginia’s All-Payer Claims Database. 

The Commission contracted with Virginia Health Information (VHI) to prepare the data set to assist carriers, providers and arbitrators in determining commercially reasonable payments and resolving payment disputes for out-of-network services. The data set is not a required fee schedule. 

The data set only includes services covered by the Virginia law, including emergency services at a hospital and non-emergency health care services provided to an enrollee at an in-network hospital or other in-network health care facility. Key services include:

• Emergency department
• Hospitalists
• Pathology
• Laboratory
• Radiology
• Anesthesiology

The data set, at its inception effective Jan. 1, 2021, must be based on the most recently available full calendar year of data, so claims are for services provided between Jan. 1 – Dec. 31, 2019. The calculations are drawn from commercial health plan claims and exclude Medicare and Medicaid claims, and claims paid on other than a fee-for-service basis. The data set includes the following amounts:

• The median allowed amount (combined in- and out-of-network) from 2019 and updated each year using a Medical Consumer Price Index (CPI) adjustment.
• The median billed amount (combined in- and out-of-network) from 2019 and updated each year using a Medical Consumer Price Index (CPI) adjustment.

Allowed amount is the sum of the amount paid by the payer and all enrollee cost-sharing.

In addition, the data set provides the calculations by geographic rating area, health planning region as commonly used by VHI in reporting, and statewide, except when suppressed if a field includes less than 30 claims.  

Updates to the data set in subsequent years must be based on the original data set adjusted by the Medical CPI. The data set that is to be used for the upcoming year will be finalized and published by November 1st. As required by Virginia law, VHI will update the data set to delineate between claims paid in-network versus out-of-network once that data is available.

Additional information about the data set methodology is found in the data set itself. 

Requesting Necessary Updates to the Virginia Commercially Reasonable Payments Data Set

Necessary updates to the Virginia Commercially Reasonable Payments Data set are reviewed and implemented on an annual basis in accordance with Section 38.2-3445.03 of the Code of Virginia. Individuals and organizations can request necessary edits to be incorporated into the following year’s data set between January 1st and June 1st of each calendar year. Requests should be limited to correction of errors or new or revised Codes. Otherwise, the original data set will be adjusted annually for inflation by applying the Consumer Price Index-Medical Component.

Any necessary update requests must be submitted by email to [email protected] and contain the following pieces of information to be officially considered for review:

Email Title- [Correction/Code Removal/Code Addition] Request for VA Commercially Reasonable Payments Data Set by [Requestor Name] with [Requestor Organization]

Body of Email- The body of the update request email must contain details for the reasoning behind each request and include any specific codes requested to be added/deleted if applicable. 

All submitted requests will be reviewed by the Bureau but are not guaranteed to be accepted. A summary of approved changes will be posted on this page once available.