Dec. 19—Hospitals and health systems are bracing to accommodate a range of issues in the new year that they are likely to experience as they treat patients who have obtained or tried to obtain coverage under the federal healthcare overhaul.

Coverage verification problems and unexpectedly high cost sharing for newly insured are among the leading issues hospitals expect among the millions of enrollees who are signing up for private insurance coverage through the Affordable Care Act (ACA), according to hospital finance experts. 

Massive and ongoing technical problems in the federal- and many state-run enrollment websites first slowed or blocked enrollments and then caused problems in transferring accurate data to insurers. An additional potential roadblock is that coverage does not begin until premium payments start. 

Confused About Coverage

The technical failings, lack of patient premium payments, and the decision by some insurers to extend plans slated for cancellation under the ACA have led to widespread confusion among enrollees, many of whom are uncertain about their insurance coverage status.

“There’s a lot of confusion over whether the website’s working, whether people are signed up for coverage, and the process for paying premiums,” Mark Rukavina, a consultant with Boston-based Community Health Advisors, said in an interview. “Some patients previously insured through Medicaid may not even understand that they need to pay monthly insurance premiums, so there’s obviously going to be a lot of education required in addition to just helping people navigate the marketplaces.”

Unresolved marketplace technical problems surrounding the transfer of enrollment data to insurers could keep insurance companies from confirming coverage with providers. Sandra Wolfskill, director of revenue cycle MAP at HFMA, said hospitals need to establish policies regarding how to assist patients who cannot verify their ACA-related coverage. Options include setting up a pending insurance account or billing the insurer based on information provided by the patient.

“Hospitals have to have a plan in place for dealing with issues such as this before Jan. 1 so that frontline registration staff will know what to do,” Wolfskill said.

Rukavina, whose many health system clients have been focused on the issue, said some hospitals may establish “transitional relief” based on the extent of ongoing insurance confirmation delays. Alternately, in nonemergent cases, hospitals may ask patients to return when their coverage is finalized and confirmed.

Additionally, hospitals should tweak their accounting systems to separately track marketplace plan-covered patients, Wolfskill said.

“Isolate the insurance exchange products within your patient accounting system,” she said. “If your accounts receivable bumps up, you can see very quickly if it’s related to insurance exchange products and manage it accordingly.”

Wolfskill said she is less concerned about problems the federal marketplace has had in transferring Medicaid enrollment data to 36 state Medicaid agencies because eligibility for coverage is easier to determine.

“It’s Medicaid; we’ve all billed Medicaid for decades,” she said. “It’s the new products that have varying kind of benefits that will be the source of problems.”

High Deductibles Raise Concerns

Wolkskill said the biggest change for hospitals in states expanding Medicaid will be an increase in patients who have a balance after insurance, particularly patients with high-deductible plans. Recent analyses have indicated that high-deductible health plans dominate the new government-run marketplaces.

Hospitals faced with a surge of patients with high deductibles should aim to follow HFMA’s new Patient Financial Communications best practices, Wolfskill said.

An influx of high-deductible plan-covered patients is the chief concern related to ACA coverage for officials at Children’s Hospital & Medical Center in Omaha.

“We believe consumers are going to buy coverage based off of price alone, and generally, that is going to leave them with significant out-of-pocket expenses that they are unprepared for,” said Brian Argo, vice president and chief revenue officer at Omaha Children’s.

The health system has worked with several venders on ways to address this expected problem, including contracting with certified application counselors to help patients navigate through the marketplace enrollment process. The health system also is creating a bank loan program to extend repayment time for patients to cover out-of-pocket expenses, which for marketplace consumers are expected to be double that which patients with employer-sponsored coverage typically owe. 

Uninsured patients also will be issued tablet computers to research their coverage options while hospitalized, including options offered on the federal marketplace enrollment and state Medicaid websites. “Providingpatients with the technology they might not otherwise have had access to could help them gain additional knowledge,” Argo said.

The health system also has hired more financial counselors to accommodate the marketplace enrollees. 

The addition of hospital finance personnel may prove particularly important for providers, given that many patients may be unfamiliar with the details of their new plans’ deductibles, co-insurance, and copayments, Wolfskill said. Processing these patients likely will take more time than processing the typical commercially insured customer because of the extra education that could be required.

“If hospitals don’t take the time to provide this education at the beginning of the patient’s encounter with the hospital, it’s going to be much harder to collect the remaining balance from their insurance down the road or determine whether the patient might qualify for financial assistance after insurance has paid its portion,” Wolfskill said.


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare.

Publication Date: Thursday, December 19, 2013