Health Insurance Exchange Confusion Hinders Patient Sign Ups

HHS Secretary Kathleen Sebelius testified before the House Ways and Means Committee on March 12 that there will be no more tweaking in the of the individual mandates under the Affordable Care Act (ACA).  This after the White House announced the extension of exemptions on the basis of hardship.

A list of those hardships, reported by the Wall Street Journal, includes more than a dozen ways that Americans could qualify, including homelessness, having utilities shut off, and having a very low income in a state that did not expand its Medicaid program. Sebelius also refused to say whether the White House goal of signing up 7 million people will be met by the March 31 deadline, when open enrollment ends. Thus, the deadline for open enrollment will not be extended, according to Sebelius, despite lack of any clear data on the number of people who have both signed up and actually paid their premium. Individuals without coverage by the deadline will face a penalty at tax time, which will likely be deducted from any anticipated tax refund next year. Any way you look at it, the hope of the White House that individuals will actually buy into the private purchase of health plans seems largely misplaced.  A great deal of the problem lies in the confusing array of plans that can be purchased through the exchanges. First, a purchaser must figure out what is being offered. Often termed “metal” plans: bronze, silver, gold and platinum, one would seemingly need to possess an advanced college degree simply to understand the choices.  The lower-premium plans, are the “bronze" plans, which carry higher initial copayment responsibilities.  This may at first seem attractive to a lower wage earner.  However, such a plan would actually benefit a higher-income individual, who could afford the 40 percent copayment.  The platinum plan, which costs more in premiums but carries a 10 percent initial copayment, would seem to be better suited to a person who lacks resources to pay nearly half of his initial healthcare expense from his own savings.  Recognizing the problem faced by lower wage earners, there are three alternative silver plans for lower income earners, which the website Obamacare 411 explains as follows:  “These three alternative health insurance plan options are only available for people that have the lower incomes.  The three health insurance plans have lower out-of-pocket expenses for people that are enrolled in the health insurance plan.  Basically, what this all means is that even though you are buying a silver tier plan; you are actually being given a better health insurance plan.

• 100 percent to150 percent of the federal poverty level (FPL) = 94 percent AV, better than average platinum plan
• 150 percent to 200 percent of FPL = 87 percent AV, better than average gold plan
• 200 percent to 250 percent of FPL = 73 percent AV, better than average silver plan

If you have difficulty following this, you see my point.  One thing people do universally seem to understand:  “What is this going to cost me?”  The answer should open more than a few eyes: All plans cap out of pocket expenses at about $6,350 for an individual, and $12,700 for a family in 2014. This means for an individual in good health, who must pay for coverage without a subsidy, the annual out of pocket expense could be well over $14,000, even with the least expensive plan.  The next question on a consumer’s mind will likely be: “What happens if I just give up and hope I don’t get sick?”  Naturally, without insurance the same individual would be liable for the entire cost of any unexpected care. But Americans have proven more than willing to accept this risk.  If a person does not choose to comply with the individual mandate before the March 31 deadline, he will face a tax bill of between $95 and $285, if I understand the rules and exemptions correctly. Finally, the largest problem facing the White House is the Republican message: “Vote against Democrats, and this all goes away.” It doesn’t, but explaining that, would be complicated.

Article  By Martin Merritt from Physicians Practice http://www.physicianspractice.com/blog/health-insurance-exchange-confusion-hinders-patient-sign-ups?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=18032014

Medical Practices Struggle to Collect Payments Due to New Payer Tactics

Over the past month or so, we've seen so many side effects from insurance companies both opting in to provide insurance through the health insurance exchanges and opting out.  Those that opted in are losing a lot of money right now due to the low number of enrollees.  Those that opted out are also losing a lot of money because they lost several of their clients when they dropped them from enrollment. 

Here's how those side effects are trickling down to medical practices: 1. Insurance companies that typically paid you within 15 days to 20 days are now holding onto that money and making more money in interest on it, leaving your cash flow suffering.  I'm also finding that they you are not paying until you call asking where that money is. 2. Insurance companies are dropping claims stating, “We never received those dates” when the two dates before and the two dates after, all within the same batch, have been paid.  This is resulting in your billing department having to follow up on all claims older than 30 days. 3. Insurance companies are creating narrow networks and patients are having difficulty finding in-network providers.  This means that many of your patients may have to pay out of network rates.  They not only have high deductibles, they also have high premiums. 4. Insurance companies are hiring outsourced auditors to review every single claim they have paid you.  If they find one error, they're coming after that money.  I once had to write a refund check for 4 cents.  Yes, 4 cents.  This can be devastating to your bank account. Essentially, these changes mean that your practice will be more and more strapped for basic cash flow.  Payroll, expenses, administrative time chasing this money down, are all a drain to your business.   Your businesses accounts receivable should be considered an asset until it starts costing your more to obtain that money than you are paid for that claim.  Here are some tips you can implement right now to help you get through this new “norm.” 1. Be sure your billing staff is calling on claims older than 30 days to 45 days if you are typically paid sooner. 2. Your billing department should have access to your clearinghouse website and be able to prove that all claims were sent on time. 3. Start keeping a list of alpha-prefixes or some type of identifier that shows it's a newer plan and you are perhaps not in network. When calling and verifying, do not assume you are in network.  Ask the rep: “Are we in network with this plan?” and if you are not, ask for out of network benefits.  I'm also seeing that many specialties are not a plan benefit, so even if you are in network, your specialty may not be covered.  In this case, you will need to turn the patient into a cash paying patient. 
Keep your eye on your accounts receivable and your bank account.  It is imperative that you own this area of your business in this volatile insurance fiasco.

Article By P.j. Cloud-moulds from Physicians Practice http://www.physicianspractice.com/blog/medical-practices-struggle-collect-payments-due-new-payer-tactics?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=18032014

Health Insurance Exchange Problems Hit Patients, Practices Hard

By P.j. Cloud-moulds from Physicians Practice

Wow, what a week!  What a year, I should say.  The state of California has seen many, many changes since January 1. How these changes are affecting physicians and practices is mind-boggling.

Here are a few of the biggest changes practices are experiencing: 1. A new California law allows patients to walk into a physical therapy office without a prior prescription and receive treatment for a specific number of visits or days.  The problem is that some insurance companies still require a prescription from a licensed physician.  Unfortunately, insurance companies often don't share this information at the verification level with the physical therapist, and the claim is denied or delayed in payment.  This has been a treat to figure out, but most of the patients have primary-care physicians that the physical therapist can fax the evaluation to, and this seems to satisfy the insurance companies need for a prescription. 2. The next change relates to the California workers compensation fee schedule.  It transitioned from very specific 30-minute timed codes to the Medicare Fee Schedule.  The problem is that very few of the workers compensation plans actually implemented this change and they are pulling the, “We didn't know” card.  Senate leaders in Sacramento have filed complaints against many of these plans. Liberty Mutual, your time to pay up has come!  I strongly advise practices to review their workers compensation claims with their healthcare and billing staff to make sure they are using the updated fee schedule, that the workers compensation plans are paying per the fee schedule, and that someone is following up with these types of claims. 3. Our latest fiasco has been my favorite so far:  Covered California. It really should be called Uncovered California.  This blog article is certainly not long enough to list all of the fiascos that we uncovered this week, but let me name a few.  Blue Shield created a “narrowed network" and many physicians that participate with Blue Shield are not in network on the new exchange plans. That means that if a patient purchases a Blue Shield exchange plan and calls for an appointment and a practice's front-office staff mistakenly believes it is in network, the patient may have to pay out-of-network rates around a 50 percent coinsurance for receiving services at your practice.   I have identified a common group number of X001004 and alpha prefixes of XEA, XEC, XED, XEK followed by 900.  These two are tip-offs that the patient is on exchange, off exchange, or underwritten.  All of these scenarios claims are processing out of network.Some of the health cards have the “Covered California” logo on them, some don't.  All of the plans indicate that they are some sort of PPO, so practices usually don't think twice about not being in network.  Patients are angry and up in arms about all of this.  While trying to figure this all out, I came across the Blue Shield Facebook page. If you want a laugh, take a look.  The company's canned responses are similar to the recorded messages and disclaimers you get when you call.  Blue Cross of California also has several new plans in which many providers are considered out of network.  Practices in the state of California may want to spend a few hours to identify patients with the alpha prefix JQD, JQM, JQN and VXB with corresponding group numbers of 0RX, 0RY (zero not “O”).  It is imperative that practices discuss these out-of-network issues with their staff so that they are aware when patients call and start yelling about getting their bills.

Article From Physicians Practice  http://www.physicianspractice.com/blog/health-insurance-exchange-problems-hit-patients-practices-hard?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=18022014

Participating in New Healthcare Exchange Plans

By Susanne Madden from Physicians Practice

It is early with regard to the healthcare exchange plans and yet practices across the country are already feeling the impact. It's not just consumers who have experienced problems while attempting to sign up for the exchange plans on the healthcare.gov website; providers too are dealing with major headaches as they navigate through the first couple of months of this new system.

Let me explain. The insurance companies created something called "narrow networks" within their full network of providers. What that means is that only a subset of physicians within any given insurance company's network "qualified" for participation in the exchange plans. The result is that while some physicians got rolled into these plans, others were excluded, even though they participate in some of the other products with that particular insurance company. For example, a physician could be participating with an HMO and a PPO-type product, but be excluded from the exchange product. This has created a dilemma for many practices. On the one hand, it means no new business coming in from new exchange members. On the other hand, it also means scrambling to hold onto existing patients that have switched to these new, lower-priced health insurance products.

The physicians that were rolled in (or opted in, in many cases) to the new exchange networks are struggling to determine new patients' eligibility under these plans. Many patients have not yet received insurance cards, and those that have are sometimes finding that their physician was mistakenly listed on the website as a "participating" provider.

In addition, those physicians who are participating with the exchange plans are finding that they are getting paid less for doing more. That is, not only are the rates less in these plans, but many patients who previously did not have health insurance may have gone without care for prolonged periods of time. As a result, they are typically sicker than patients who have been under care over time.

Also, signing up for participation in these plans means accepting a lower payment rate because the insurance companies are offering these as "budget" plans with low premiums. Naturally, the discounts have to come from somewhere and this is in the form of lower payments to physicians who participate with these plans.

So where does that leave things for physicians?

Here are four points to consider:

1. Physicians need to know whether they are participating with an exchange plan.

This can usually be readily discovered by looking yourself up on an insurance company's online directory. But don't just trust the data that you find there; double-check by calling the insurance company and verify that you are in fact participating with an exchange plan (there have been many errors on these sites so far).

2. Physicians need to determine what their fee schedule is going to be.

Ask the insurance plan to send you a sample for your specialty or send them your highest utilized codes for pricing.

3. Physicians need to communicate very clearly with patients if they are not in the exchange plans.

Hang posters on your waiting-room walls and get communications out to patients to explain that the insurance company (if this is the case) has decided to exclude you from the exchange product. Many patients wrongly assume that their physician is automatically in the network, so do your best to educate them as soon as possible.

4. Physicians need to quantify the damage.

Take note of the number of patients that you may lose due to their choice of plan and appeal to the insurance company to see if there is a way that you can retain them. If you purposefully opted out of the exchange network then it is unlikely that you can hold onto these patients. But if you were excluded from the network, you may be able to appeal ― in doing so the plan might make an exception and add you in.

If you are participating with an exchange product and you find that you are receiving an influx of these patients, my best advice to you is to set up some very good patient education materials and tools around the most frequently seen chronic conditions, in order to help manage what may be a sicker population of patients. Don't be afraid to look at what the insurance company is offering in terms of chronic-care support. Many have teams of nurses that help to manage the patient's care and do a relatively good job of feeding that information back to the primary-care physician.

Lastly, remember that it is still early. There are going to be a lot of missteps under this new system, on all sides. So I suggest hanging in there to see how things shake out. Like any new program it will take a while to work out the kinks.

Article by: Susanne Madden, MBA, is founder and CEO of The Verden Group, a consulting and business intelligence firm that specializes in practice management, physician education, and healthcare policy. She is also COO, National Breastfeeding Center, and cofounder, Patient Centered Solutions. She can be reached at madden@theverdengroup.com or by visiting www.theverdengroup.com.

From Physicains Practice http://www.physicianspractice.com/healthcare-reform/participating-new-healthcare-exchange-plans?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=27022014