HIE plans are designed to offer “lower cost” plans to individuals that may or may not have an existing condition. Physician offices are an easy target to control cost. To that end many HIE plans continue limiting provider networks and to push down physician compensation levels, often to unacceptable levels. Each office will need evaluate each HIE plan thoroughly before venturing into exchange patient care. First, ask if it makes business sense for the practice. Understand each company participating in the HIE will likely offer different plans and most seem to favor HMO-style closed networks but the requirements for each plan may differ in access requirements to specialists, deductible, co-payment and co-insurance to name a few.
Also, under some agreements doctors don’t have to agree (may not require a signature – your included unless you decline) to the new rates and requirements. If your practice or Doctor is automatically enrolled in the new network, you may have a limited time to opt out (i.e., 90 days or less). Understanding the core aspects of HIE bronze, silver, gold and platinum-level plans and how HIEs will impact your practice’s revenue cycle may not be fully possible until a few months in to the program.
In the short term you will have to do your best to project what is correct for your practice and your marketplace. Items to consider include:
- A potential influx of newly covered patients, this could be good but could be bad for overall financial health depending upon contract, demographics and current patient mix.
- Health insurers offering qualified health plans on the ACA exchanges (issuers) must provide a three-month grace period to enrolled individuals who haven’t paid their premiums.
- During the first 30 days issuers must pay for claims, but in the last 60 days they may (will) hold claims.
- If patient’s coverage is cancelled after 90 days for failure to pay premiums, issuers are not required to pay any claims for services furnished in the last 60 days of the three-month grace period. Practices must then attempt to collect from the patient.
- Eligibility verification requires attention regarding effective dates for coverage. ACA exchange plan coverage began as early as January. 1, and the initial enrollment period remains open until March. 31. Coverage effective date depends on when a patient enrolls. If a patient signs up on or before the 15th of the month, coverage begins on the first day of the following month. If a patient signs up after the 15th of the month, coverage begins a month later.
- First, determine which payers will be serving exchange patients.
- Determine which if any plans have specific obligations of providers imposed by the payers and/or exchanges.
- Compensation formulas and payment terms need to be negotiated or contracts cancelled if they do not meet practice financial goals.
- Existing managed care contracts may have hidden terms that apply to exchange patient care so review each contract thoroughly and contact payers for updated requirements for 2014.
- Develop effective patient responsibility payment collection skill sets. Training and ongoing education of staff is imperative. Additionally your staff will need access to accurate data for co-payments, deductibles, eligibility, co-insurance and pre-service referral requirements.
- Update practice policies to provide to patients with updated notifications of collection policies and procedures implemented by the office. Make sure that staff is aware of policies and that they are enforced by your personnel.
These and more issues necessitates the practice understand the true costs of the plan and cost of providing patient care before signing the agreement or deciding to continue with a plan. For more information on how we can help please prsconsulting@prsnetwork.com contact us.
