Author Topic: Office fiancial policy changes for upcoming changes with ACA  (Read 5056 times)

PMRNC

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Office fiancial policy changes for upcoming changes with ACA
« on: November 29, 2013, 03:17:34 PM »
For last 2 months I’ve been going over each of my clients office financial policies and we’ve been getting ready for the 2014 changes coming with regards to the exchange plans.  One of the things we are having trouble with is the 90 day grace period and how we can protect ourselves from this.
The exchange plans all come with a 90 day grace period, meaning you can receive benefit payments with contracted plan and AOB and then 2-3 months later find out the policy was terminated. I’d like to have my clients implement a policy that would allow for us to submit the refund to the carrier requesting the overpayment back ONLY if the patient has sent in the payment. Yes I already have myself and practice attorney’s reviewing contracts and renewals/revisions as they come in.   There has got to be some legal way for the practice to handle these. 90 days is a while and it’s going to happen a lot with these individual plans.

Anyone have ideas or have implemented any changes that might help with this?
Linda Walker
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shanbull

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Re: Office fiancial policy changes for upcoming changes with ACA
« Reply #1 on: December 02, 2013, 11:38:28 AM »
Oh dear, this is going to be a headache. Do you have the wording straight from the ACA on this one? A lot of these time frame policies have at least some type of guidelines in the law regarding what to do with these weird situations. I will have to alert my boss to this as well so we can revise our contracts, if you can find the exact provision about it so I can pass it on, that would be great.

This seems like an opportunity for fraud waiting to happen. 90 days is an extremely long window to be in the dark about whether a policy is active.

PMRNC

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Re: Office fiancial policy changes for upcoming changes with ACA
« Reply #2 on: December 02, 2013, 11:51:32 AM »
This provision of the rule applies to all people in all states who obtain subsidized coverage through the state exchanges. It's estimated that 80% of newly insureds will fall into that category. Under the current rule as it is now, Insurers ofering plans on the exchanges MUST provide a three month grace period to individuals who have enrolled and who have stopped paying their premiums. IN the first 30 days the insurer must continue to pay incurred claims. For subscribers who FAIL to pay premiums within the 90 day grace period and who's coverage is terminated, payers are NOT required to pay for claims incurred during the last 60 days of the 90 day grace period.   

This is similar to what happens now with anyone on COBRA.

My idea and I am having my clients forward contracts over as they are revised, is to check the contract. See if we can request all patients who fall into the category with the 90 day grace period, bring in their premium statement for the current month. For example, a patient on a one of the state exchange plans that comes in on 3/1/2014 should be able to provide a proof of premium statement for the month of march. If they do not they need to pay in full (Again, going to have to review the legalities of this with each contract provider is par with) OR we as the office can HOLD the claim and it would not be subject to late filing, once we receive proof of payment of premium from the pateint we know we can submit the claim with the assignment of benefits.   FOR non par I already talked to one of my clients attorneys on this and we can request payment in full (giving them itemized bill to submit) any time in those 90 days.

I'm going to be swamped looking at contracts. Last week they started sending us letters that contract amendments were coming and would be here by 12/15 and with a few TPA carriers we received notification that plan contracts and fee schedules would not change.

What I'm really worried about is claims submitted in those first 30 days that were paid and then subscriber does NOT pay premium and terminates, the carrier will have a right to come after the provider to recoup.   ERISA claims and verbiage would allow us to fight this in most cases. going to be a mess.
Linda Walker
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RichardP

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Re: Office fiancial policy changes for upcoming changes with ACA
« Reply #3 on: December 02, 2013, 02:05:51 PM »
Linda, assuming I understand you correctly:

1.  You are discussing only that situation where patient has subsidized coverage;
2.  Carrier is required to give patient 90 days in which to bring his account current before they cancel his insurance;
3.  Ninety-day grace period does not apply to non-subsidized coverage.

It would be helpful if you could give us the Section of the ACA where this language appears, or a link to that language.
-------------

Let's assume the 90-day grace period begins on Jan 1, xx.  Customer paid insurance policy payment on 12-1, xx, but has not paid the premium due Jan 1.  He will not pay the premium due on Feb 1 or March 1 either.  Customer's 90-day grace period ends on or about March 31.

Q1:  Are you saying that the insurance carriers must pay for appropriate medical expenses incurred by this customer during the first 30 days from Jan 1?  (That would be the first 30 days after payment is due but not received)

Q2:  Are you saying that the insurance carries do not have to pay for any appropriate medical expenses incurred by this customer for days 31-90, as calculated from Jan 1?

Q3:  Are you saying that required payments made to doctor by insurance carrier, during days 1-30, can be clawed back from the doctor if patient / customer does not bring his insurance payments current by day 90?  Or will this be an expense the insurance companies are required to absorb?

Q4:  Will there be any way for the doctor's office to identify these subsidized insurance accounts that are subject to the 90-day grace period?  That is, will there be any way for a doctor to determine what his exposure is to the amount of money he might have clawed back?

Q5:  Does the ACA allow / require the health insurance carriers to require that participating providers provide care for the subsidized-insurance patient during days 31-90 when patient has not paid their premiums - without charging the patient directly?

Q6:  Assuming customer brings insurance premium current on Day 89, is insurance carrier required to pay for all appropriate medical expenses incurred during days 31-89?

RichardP

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Re: Office fiancial policy changes for upcoming changes with ACA
« Reply #4 on: December 02, 2013, 02:21:38 PM »
See if we can request all patients who fall into the category with the 90 day grace period, bring in their premium statement for the current month.

I assume you will look at the premium statement for proof that the previous month's payment was received by the insurance carrier.  Suppose the patient hasn't yet received the premium statement?  And, even if they have a current premium statement, suppose they made the premium payment with a bad check that wasn't caught before the current premium statement was sent out?

If the doctor can make the subsidized-insurance patient pay for his services before he receives them, how will the ACA have been any help for that patient?  The supposed reason the patient did not seek health care was because he couldn't afford to pay for it.  So how is that patient now supposed to be able to afford what he couldn't before?  It doesn't matter that the insurance company will ultimately reimburse him.  It matters that he doesn't have the cash up front.

A useful solution is going to have to account for all of these issues, and others.

PMRNC

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Re: Office fiancial policy changes for upcoming changes with ACA
« Reply #5 on: December 02, 2013, 07:18:09 PM »
I did give the verbiage.. but it's on Pg 292 if you have the full act in front of you.. (pages vary when you have them printed, mine is printed so it's my page 292, Line #9.. repeat what I posted: This provision of the rule applies to all people in all states who obtain subsidized coverage through the state exchanges. It's estimated that 80% of newly insureds will fall into that category. Under the current rule as it is now, Insurers ofering plans on the exchanges MUST provide a three month grace period to individuals who have enrolled and who have stopped paying their premiums. IN the first 30 days the insurer must continue to pay incurred claims. For subscribers who FAIL to pay premiums within the 90 day grace period and who's coverage is terminated, payers are NOT required to pay for claims incurred during the last 60 days of the 90 day grace period.   

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I assume you will look at the premium statement for proof that the previous month's payment was received by the insurance carrier.  Suppose the patient hasn't yet received the premium statement?  And, even if they have a current premium statement, suppose they made the premium payment with a bad check that wasn't caught before the current premium statement was sent out?

I think your splitting hairs. Again, I'm discussing these processes with my attorney and the attorneys of the providers I work with as this is above and beyond my scope. BUT it is going to effect us.. and if you charge on a %.. good luck to you as this will be another reason to get as far away from % billing as you can.
Like I said I don't have details pending but I've consulted with legal counsel on our options here as I do believe we have a legal right to request proof of payment. I would imagine if a patient writes a bad check they have to deal with several legalities of doing so and one would be giving us a false statement. But I'm not going to assume anything. I'm going to wait and go through each contract with my clients par agreements and see where we have legal options. I will say this.. since they will only pay the first 30 days of benefits.. I can't see why legally we cannot require up front payment on the other 60 days from this provision.
Linda Walker
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shanbull

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Re: Office fiancial policy changes for upcoming changes with ACA
« Reply #6 on: December 03, 2013, 12:39:29 PM »
Thanks for all the info! We do have a state exchange so this definitely affects us. Medical assistance patients and patients with a tier above Medicaid (it's a state-run program) are now required to get their insurance through the exchange, so I believe this involves all of them as well. I let my boss know about it and we're worried that we can't ask for a contract amendment because we're an independent clinic, so taking our business elsewhere isn't as great a threat as it would be if we were part of a bigger system. Please keep us updated on how things go. I would also be interested to see how other independent clinics address this. Our patients are often non-English speaking, elderly (without Medicare eligibility) and/or very poor so asking for proof of premium payment is a little more difficult for us than for some, and we prefer not to create any barriers to care for these people because they are already vulnerable and know very little about how insurance works. Most of the time, lapses in coverage are totally unintentional on their part. It's hard enough to get things sorted out with medical assistance gaps already and they only have a 30 day window.

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Q4:  Will there be any way for the doctor's office to identify these subsidized insurance accounts that are subject to the 90-day grace period?  That is, will there be any way for a doctor to determine what his exposure is to the amount of money he might have clawed back?

The answer to the first part of this question is no. There is no difference in the way the insurance ID cards or benefits summaries will look. They policies are still issued by the private insurance companies, so they will have the same uniform appearance as all of the other policies these insurers administer. Some insurance companies do offer specific plans that are only available on the state exchanges, but the only way to identify them is to know the actual plan names. Since the minimum requirements of the ACA apply to all non-grandathered and non-indemnity plans, the coverage details will not be a clue either. This is by design.

Merry

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Re: Office fiancial policy changes for upcoming changes with ACA
« Reply #7 on: December 03, 2013, 12:50:38 PM »
Sitting here thinking about this..and Linda and I have had extensive conversations about this over the weeks. I think her bringing this up is so important. We are, though just a few people. I cannot imagine what chaos this will cause in the offices that have no clue. These are the very offices who do not have people like us..who make sure that their NPP's were updated in time for the September 23rd deadline, who changed their business associate contracts and who continue to keep the doctors updated.

And I see this also as an opportunity for scams. Person pays one month premium..gets the care that they need..be it a big procedure even involving surgery etc and then does not continue paying.
Do not see this please as a political statement. Far from it. Just that people who put this together were not thinking of the ramifications to the providers.

PMRNC

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Re: Office fiancial policy changes for upcoming changes with ACA
« Reply #8 on: December 03, 2013, 01:25:52 PM »
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The answer to the first part of this question is no. There is no difference in the way the insurance ID cards or benefits summaries will look. They policies are still issued by the private insurance companies, so they will have the same uniform appearance as all of the other policies these insurers administer. Some insurance companies do offer specific plans that are only available on the state exchanges, but the only way to identify them is to know the actual plan names. Since the minimum requirements of the ACA apply to all non-grandathered and non-indemnity plans, the coverage details will not be a clue either. This is by design.

ALL of the individual subsidized plans on the exchanges WILL be identified with the metal plan as well as the individual or family identifiers. ALL of them with those criteria will fall into the 90 days grace period for which the first 30 days are paid leaving the provider at risk. ONE of my clients attorney's has already gotten back to us and he will be requiring all plans on the state exchanges to bring in proof of premium payments. We are waiting however to modify office policies with reviews to any amended contract plans. I have one provider who has already said he'll get out of any plan that doesn't allow him to minimize his risk with this grace period. He's already given me instruction to review and let him know and we will go forward getting out of those plans.
Linda Walker
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shanbull

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Re: Office fiancial policy changes for upcoming changes with ACA
« Reply #9 on: December 03, 2013, 04:28:05 PM »
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The answer to the first part of this question is no. There is no difference in the way the insurance ID cards or benefits summaries will look. They policies are still issued by the private insurance companies, so they will have the same uniform appearance as all of the other policies these insurers administer. Some insurance companies do offer specific plans that are only available on the state exchanges, but the only way to identify them is to know the actual plan names. Since the minimum requirements of the ACA apply to all non-grandathered and non-indemnity plans, the coverage details will not be a clue either. This is by design.

ALL of the individual subsidized plans on the exchanges WILL be identified with the metal plan as well as the individual or family identifiers.

Oh good, this is totally different from what I was hearing from the people who do verification here. I did just sign up on the state exchange today for my own policy (yep, I'm one of the people who had a junk insurance plan, go figure - at least I knew it was junk) so I can let you all know how my card and verification look compared to people with non-exchange plans for this insurer.

One thing I did notice when signing up, there was no mention of this grace period on the consumer end. It just said "payment is due by the 15th for coverage starting on the 1st of the next month." So fortunately, unless patients are experts on the ACA, they will probably have no idea what they can get away with. Still, the problem should not exist in the first place. I don't think it's political to point out major problems with the law going into effect. Heck, I have always supported the law (well, actually, I supported a single payer model) - that doesn't mean it's perfect or without serious issues that need to be ironed out. I'm just hoping something major isn't discovered in the eleventh hour that is even more problematic than this. We don't have the money to get billing held up for months on end indefinitely.

PMRNC

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Re: Office fiancial policy changes for upcoming changes with ACA
« Reply #10 on: December 03, 2013, 04:38:28 PM »
Premum requests for the Exchanges won't be due until 1/1/2014 and the premium statements won't have this on them however if you look at the insurability statement that comes when you sign up and with your first payment due.. you will see the grace period displayed.
Linda Walker
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shanbull

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Re: Office fiancial policy changes for upcoming changes with ACA
« Reply #11 on: December 03, 2013, 04:41:58 PM »
Oh, I think I know why I didn't see it. We have the option to pay immediately via the exchange (which I did) or to request a bill from the insurance company, which presumably has more info. I will probably get a statement about it in the mail.

shanbull

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Re: Office fiancial policy changes for upcoming changes with ACA
« Reply #12 on: December 05, 2013, 09:51:44 AM »
We've decided on a policy for our office, it's not going to be completely effective but due to our unique limitations, it's the best we can do without inconveniencing our patients:

Anyone who comes in with an insurance card from the state exchange will have a billing alert added to their account. The front desk will contact the insurer to try to find out if payment was received for the first month's premium. If this information is not something the insurer will release, a second note next to the previous one will be added. They can then request confirmation of payment if the patient has it, but we will not require it because most of our patient don't keep paperwork like that with them.

This will at least let us keep track of how many people are in this situation, we do not expect a whole lot because we have the highest insured population of any state already. If we see a spike in people with these plans we may need to revisit the policy, but for now we just can't sacrifice access to care for protection from recoupment. The doctors agree that this is a risk they need to take. It's a bad situation to put doctors in who already take a hit serving vulnerable populations, but most of our doctors are already resigned to this anyway or they wouldn't be working here.

RichardP

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Re: Office fiancial policy changes for upcoming changes with ACA
« Reply #13 on: December 05, 2013, 10:01:09 PM »
Here is a useful read on who will qualify for Premium Tax Credits.  All Premium Tax Credits are payable in advance.

http://www.cbpp.org/files/QA-on-Premium-Credits.pdf

shanbull, you say you have the highest insured population of any state.  Consider two things:  First: as people learn how to calculate the Premium Tax Credit, you may discover that many of the already-insured in your state qualify for a Premium Tax Credit.  They would be foolish to not take advantage of that if they can.  Second:  Many businesses are shedding their health insurance programs in any way they can, forcing the already-insured into the exchanges.  That may accelerate when the one-year extension runs out for business to participate in the ACA.  I think we will see many more people with Premium Tax Credits several years from now than we see now.

PMRNC

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Re: Office fiancial policy changes for upcoming changes with ACA
« Reply #14 on: December 10, 2013, 07:32:08 PM »
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Here is a useful read on who will qualify for Premium Tax Credits.  All Premium Tax Credits are payable in advance.

http://www.cbpp.org/files/QA-on-Premium-Credits.pdf

shanbull, you say you have the highest insured population of any state.  Consider two things:  First: as people learn how to calculate the Premium Tax Credit, you may discover that many of the already-insured in your state qualify for a Premium Tax Credit.  They would be foolish to not take advantage of that if they can.  Second:  Many businesses are shedding their health insurance programs in any way they can, forcing the already-insured into the exchanges.  That may accelerate when the one-year extension runs out for business to participate in the ACA.  I think we will see many more people with Premium Tax Credits several years from now than we see now.

Good INFO.. however.. as medical billing companies, and even medical billers in doctors offices.. we should NOT be involved with premium's or tax credit's ASIDE from finding out if they are in the midst of the grace period or not. Their tax credits, their subsidies are not our concern and have NO baring on our jobs.

Just trying to clarify this because many are making this much harder than it needs to be from our end.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com