General Category > General Questions
Office fiancial policy changes for upcoming changes with ACA
PMRNC:
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?
shanbull:
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:
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.
RichardP:
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.
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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:
--- Quote from: PMRNC on December 02, 2013, 02:51:32 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.
--- End quote ---
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.
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