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According to feedback from nine Forum listserv members, healthcare finance leaders have more questions than answers about how to bill insurers under new exchange plans come Jan. 1, as well as how to determine which insurance products patients are enrolled in.
“Outside of receiving a provider manual from one carrier, we have not been told of any exchange plan specific requirements for billing,” said one managed care director from a Chicago hospital who participated in the informal Forum listserv poll between Nov. 6 and Nov. 8.
A second Forum member from southern Louisiana noted: “Our insurance representative, when questioned about reimbursement, stated that we would be reimbursed by contract rates. This is the only information we have.”
She also points out: “Even reimbursement at contracted rates does not mean a lot given the high deductibles and copays.”
However, revenue cycle leaders at healthcare organizations that have formally contracted with exchange plans reported getting some details from insurers. “Exchange plans that we are contracted with have either added addendums to our current contract, or they are using our current full-panel contract rates and including us in their exchange-provider panel,” said a managed care director at an Ohio health system. “In all cases, the billing process is the same as we would use for their non-exchange plans.”
Several listserv respondents pointed out the need to carefully scrutinize exchange contracts before signing. “For the most part, they are selling either a PPO or HMO with a variety of deductibles—yet they were proposing a reimbursement of a Medicaid rate (until we called them out on it),” said a revenue cycle leader from a New York state health system.
A few respondents said they had been included in exchange plans without signing a contract. “One payer is attempting to utilize our contracted rate for their narrow-network exchange plan—but we are not included in that exchange-narrow network plan,” said the Ohio managed care leader. “Since that rate assumes we are in-network (which is not the case for a narrow-network plan that excludes us), we are not allowing this language. We are also reaffirming to this plan that we’ll be billing it/their members as we would any non-contracted plan.”
The Ohio leader also points out another potential problem with non-contracted plans: “We are concerned whether members will know to use in-network facilities/physicians.”
Only a few Forum listserv respondents have seen what the ID cards for exchange products will look like. “We’re hopeful that we can properly identify this population since we know the product name of the plan,” said the Chicago managed care leader. “We’re hoping that’s the identifier on the ID card. If it isn’t, then there will be a tremendous amount of corrections on the back end once payments come in since the rates for these plans differ from the current HMO/PPO rate structures.”
The revenue cycle leader at the New York state health system also has concerns: “We will not really know which plan the patients are falling into as far as out-of-pocket costs. We could see someone present with an insurance card that had a $5K deductible and, thus, are virtually uninsured. It increases our exposure and impacts our ability to collect.”
On seeing these Forum responses, HFMA’s Chad Mulvany, director, healthcare finance policy, strategy and development, advises revenue cycle leaders to bolster their registration, scheduling, and verification processes before Jan. 1. “This uncertainty around exchange products increases the need for good front-end processes, particularly for scheduled services, to help beneficiaries understand their deductibles and coinsurance/copayments.”
The article is based on an informal poll that was conducted on the HFMA Forum listserv between Nov. 6 and Nov. 8, 2013. Nine Forum members responded to this poll.
Learn more about HFMA Forum—and join.
See this Kaiser Health News article for physician reactions to exchange plans: http://www.kaiserhealthnews.org/Stories/2013/November/19/doctor-rates-marketplace-insurance-plans.aspx Here's one excerpt from the article: A survey by The Medical Society of the State of New York found that 40 percent of more than 400 physicians who had responded so far said they chose not to participate in a health insurer’s exchange plan, and one-third said they did not know whether they were participating or not.Two-thirds indicated they had received no information about reimbursements; of those who did ge that information, “a significant majority indicated that the reimbursement generally was well below what the insurer pays in other contracts,” according to a statement from the society’s president Dr. Sam Unterricht.
Russ Graney, founder and CEO for Aidin, and John Laursen, head of business development for Aidin, share insights on how to improve care transitions between acute and post-acute care settings and incentivize high-quality patient outcomes.
Scott Elston, strategic accounts manager, GE Healthcare Services, describes how substantial cost reduction in health care requires rethinking business strategy and asset use.
Robert Williams, MD, director, Deloitte Consulting LLP, and Arielle Freiberger, product strategist, ConvergeHEALTH by Deloitte, explain how sophisticated retrospective, real-time, and predictive data analytics can inform decision making to reduce costs and improve care.
Stuart Hanson, director of business development (healthcare solutions) at Citi Retail Services, discusses how improving the payment experience can benefit consumers and healthcare providers.
Scott Schmidt, vice president, Cerner RevWorks, LLC, shares insights on best practices for maximizing a revenue cycle management partnership.
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