Current uncertainty around exchange products increases the need for solid front-end revenue cycle processes.


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.

Minimal Billing Specifics

“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.”

Payment Rate Concerns

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.”

Insurance Verification Issues

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.

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