Jeff HeltonIt looks like healthcare reform and the health insurance exchanges are going to happen in some form or fashion, despite current problems with enrollment in the exchange program. However, one additional controversy has arisen that creates an area of concern for healthcare providers and successful management of the revenue cycle in this new era. Although expansion of health insurance coverage seems like a good thing for providers, I would argue that that benefit comes with some additional challenge. Originally, the common perception was that people who liked their health plans would be able to keep those health plans. Obviously, that is not entirely true given recent publicity about insurers canceling plans that are not grandfathered under the Accountable Care Act (ACA). Although the cancellations were appropriate under provisions of the act, clearly the American public has a knowledge gap on regarding the significance of ACA with respect to any individual’s particular circumstances. As an industry, we can be instrumental in educating the public about the Act—and hopefully avoid future problems in getting paid for services under these new insurance plans. That statement applies especially to the ”grandfathered” plans that will remain in effect after Jan. 1.

Recall that the “grandfathered” plans are those plans that were in force prior to enactment of the ACA on March 23, 2010. As long as those plans meet the preexisting condition, dependent coverage to age 26, medical loss ratio, and lifetime limit provisions of the Act, they can remain in force after Jan. 1, 2014.  Plans lose their “grandfathered” status if they have made any substantive change to plan provisions after March 23, 2010. Important to remember is the fact that those “grandfathered” plans do not have to cover the mandated benefits under the ACA. So we have to be alert to the continued challenge of wide variations in covered benefits available in commercial health insurance plans. As before, failure to verify benefits properly will leave providers with claim denials to resolve and, with that, potential balance billing and the associated patient relations problems. In some respects, expansion of health insurance coverage also expands our need to be thorough and diligent in our front-end revenue cycle processes.   I would argue that this is not all bad. Members of HFMA can (and should) be valuable community resources to help our friends and neighbors understand how things will work in this new era of insurance expansion. Helping people understand simple but high-risk details such as that small provision in the patient’s coverage stating that the plan is ”grandfathered” can be a valuable service to the community even as it helps us unnecessary claim denials and delays in payment. Serving in that expert role simply adds to the credibility and community benefit we can provide as representatives of our organization.

No one will mistake the ACA as something easy to read or understand. However, those of us who work in the industry on a daily basis are more able than the average person to understand many of its provisions—and their consequences. What someone understands about an insurance plan today may not be true tomorrow. Let’s be available to our friends and neighbors, and even reach out to them to help them through this challenging time of change.

Jeffrey Helton, PhD, FHFMA, CMA, CFE, is assistant professor, Metropolitan State University of Denver, and a member of HFMA’s Colorado Chapter.

Publication Date: Monday, November 04, 2013