Health care exchange update

Saturday, March 01, 2014 11:19 AM
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Payment issues may start in March

Kate Alfano, CMS contributing writer

Connect for Health CO

Open enrollment in Connect for Health Colorado, the state’s health insurance exchange, ends on March 31. Exchange staff anticipate a surge of patients signing up for health plans before the deadline. So far, Connect for Health Colorado reports that close to 85,000 Coloradans have purchased private insurance plans and roughly 56 percent of these enrollees qualified for tax credits and financial assistance. Nearly 136,000 have qualified for Medicaid since Oct. 1.

But with the newly insured comes a risk for payment issues to physician practices starting in March due to the 90-day grace period. Per federal rule, patients who receive federal subsidies to purchase exchange plans have a 90-day grace period for non-payment of premiums. During the first 30 days the health insurer must pay for claims as if the patient were eligible, but in the last 60 days they can suspend claims. If the patient’s coverage is cancelled after 90 days because of non-payment of premiums, the insurer may deny all suspended claims for services furnished during the 31-90 day time period.

Physician practices could therefore be in a position of providing services for up to 60 days, only to be stuck with the prospect of either having to absorb the costs as bad debt or attempting to collect arrears from patients who may not have the means to pay these bills given that they couldn’t pay for their premiums.

Federal guidance states, “Issuers should notify all potentially affected providers as soon as practicable when an enrollee enters the grace period, since the risk and burden are greatest on the provider.”

The Colorado Association of Health Plans surveyed six of its member plans and all reported that they offer immediate eligibility verification by phone that is updated either daily or in real-time; five can immediately report by phone the patient’s effective date and whether the patient is in the grace period. Five offer verification by electronic transaction and four offer verification by secure web portal.

One plan reported that it will have a field in its core system labeled “paid-through date” that indicates the end of the month that a patient’s premium is paid through. If on the date of eligibility check that date is more than one month past, then the patient is in the three-month grace period. That information, along with an explanation, would be provided by phone, electronic transaction or secure web portal.

To help lessen the potential impact of the grace period on the viability of your practice, the American Medical Association and the Medical Group Management Association offer the following checklist for exchange implementation.

  1. Double-check whether your practice’s physicians are participating with ACA exchange products.
  2. Determine your practice’s ability to accept new patients.
  3. Train office staff who speak with callers and patients to be able to provide resources to patients with insurance and enrollment questions. These might include the Connect for Health Colorado call center phone number and website, or personal assistance sites available through the federal exchange at
  4. As with other insurance, check patient eligibility, coinsurance, deductibles and copays for each visit. The AMA provides a toolkit to help practices collect more at the time of service. Click here to go to the AMA’s website to access this resource.
  5. Be prepared to discuss out-of-pocket expenses and the cost of care with each patient. Discuss your financial policies with patients and try to collect all copayments and deductibles when the patient checks in.
  6. Know the essential health benefits in your state that are in addition to the federally required benefits.

The problem of cancellations due to non-payment is not new. However, it has the potential to become a bigger issue with the exchanges and federal subsidies.

The Colorado Medical Society encourages members to take advantage of resources on the exchange from the AMA, MGMA and health insurers to ensure your practice is not vulnerable.

Posted in: Colorado Medicine | Practice Evolution | Payment Reform | Interacting With Payers | Initiatives | AMA


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