| by AJ Riviezzo |
| With the implementation of the various Affordable Care Act plans, some new issues have come to the fore. Each state’s payers seem to have different aspects and nuances with their plans. Some themes, however, are starting to become a bit more prevalent.
Contracting – Even if you have always accepted All Products from a payer, with their new ACA plans you may or may not be in network. Even when you call for benefits, you are often not told you are out of network. Finding out when the claim pays as out of network can be a bit painful. We recommend calling your top four or five payers to find out if they have an ACA plan(s) and if you are in network with those plans. You should also request a copy of the ACA card format so you have some hope of identifying these plans upon check-in.
Reimbursement – In a number of states reimbursement is sub-par. In California some of the plans are paying at 70% of their normal contracted rate (in OR out of network). Lower rates have been seen in other areas but not somewhere south of the Medicaid (MediCal) reimbursement rates like in California. When placing the call we recommend above, ask if you can have two or three codes (your ablation, bilat US, and new pt. visit code) priced. Three codes can usually be done over the telephone.
Payments – The ACA also has a clause designed to protect the patient/consumer but this same clause can create havoc for a practice. The insurance carrier has to allow the patient a window of three months of a non-payment. Unfortunately, during that time a practice is being told the patient has coverage, is performing authorizations, and generally working normally. If, after three months has passed and there is still no premium payment, the insurance carrier gets to note that the patient now has no coverage for months two and three. Worse, even if you received payment for say month two, the payer can now request a recoupment of that payment. Our advice is to have some language in one of the patient consents noting they will be responsible for the full billed charges if the claims deny for non-payment of the premium. It is also illegal for the practice to pay the premium on behalf of the patient.
Deductibles – As we have noted before, many of these plans have very high deductibles. The patients believe they have ‘good’ coverage because that is how it is sold. Many of them are shocked that they may have to pay upwards of five to seven thousand dollars for treatment… per year. Please ensure that you collect as much of the deductible monies up front as you can.
Somehow ‘caveat emptor’ now applies to the seller of the services almost as much as the buyer of services. Being careful on the front end may help keep your bottom line profitable. |
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