Health exchanges could bring unpleasant surprises

SAN FRANCISCO – Stand by for some unexpected and potentially nasty surprises when the health insurance exchanges start up in 2014.

The exchanges will start enrolling patients this fall and begin sending information to patients and physicians this summer. Health insurers will begin sending new contracts to physicians around then too.

But there’s information available now that should send shivers up physicians’ spines, Elizabeth McNeil, vice president of the center for federal government relations at the California Medical Association, said at the annual meeting of the American College of Physicians.

A little-noticed provision of the Affordable Care Act gives exchange participants a 90-day grace period to pay their premiums. This was designed to provide a cushion for people who might not be used to paying health insurance premiums. Insurers have to pay all claims incurred by the patient in the first month, but in the second month, if the patient is still delinquent, all claims can be held as pending. By the third month, if the patient still has not paid, the insurer can terminate him or her.

The physician then has to collect payment for all outstanding claims from the patient. "This is going to put you at a lot of risk," Ms. McNeil said. "You’re going to have to be very vigilant with the exchange patients in watching what’s going on."

Many patients who’ll get coverage through the health insurance exchanges will also have much larger out-of-pocket costs than they are used to paying, Ms. McNeil said. In California, the CMA estimates an individual could face as much as $6,400 in uncovered expenses, and a family, up to $12,800.

Physicians also will need to pay attention to the contracts they sign with health insurers participating in the exchanges. The exchange could bring a large number of new patients to the practice and physicians need to think about how many additional patients they can actually accommodate, she said.

Another thing to keep in mind: Does the contract have an all-payer clause that requires your practice to accept exchange patients? When negotiating rates, be aware that many patients who gain coverage via the health insurance exchanges will have pent-up demand for health care because they have been uninsured or underinsured, Ms. McNeil advised. Their care could be more complex and time consuming, so doctors will want to be sure that reimbursement rates are adequate to cover this care.

Lawrence Kosinski, M.D., MBA, AGAF, chair of the AGA Institute Practice Management and Economics Committee, said: "The health insurance exchanges created in the ACA will have very significant financial consequences for our practices. It’s time for all of us to become knowledgeable of their ramifications."

On Twitter @aliciaault

SAN FRANCISCO – Stand by for some unexpected and potentially nasty surprises when the health insurance exchanges start up in 2014.

The exchanges will start enrolling patients this fall and begin sending information to patients and physicians this summer. Health insurers will begin sending new contracts to physicians around then too.

But there’s information available now that should send shivers up physicians’ spines, Elizabeth McNeil, vice president of the center for federal government relations at the California Medical Association, said at the annual meeting of the American College of Physicians.

A little-noticed provision of the Affordable Care Act gives exchange participants a 90-day grace period to pay their premiums. This was designed to provide a cushion for people who might not be used to paying health insurance premiums. Insurers have to pay all claims incurred by the patient in the first month, but in the second month, if the patient is still delinquent, all claims can be held as pending. By the third month, if the patient still has not paid, the insurer can terminate him or her.

The physician then has to collect payment for all outstanding claims from the patient. "This is going to put you at a lot of risk," Ms. McNeil said. "You’re going to have to be very vigilant with the exchange patients in watching what’s going on."

Many patients who’ll get coverage through the health insurance exchanges will also have much larger out-of-pocket costs than they are used to paying, Ms. McNeil said. In California, the CMA estimates an individual could face as much as $6,400 in uncovered expenses, and a family, up to $12,800.

Physicians also will need to pay attention to the contracts they sign with health insurers participating in the exchanges. The exchange could bring a large number of new patients to the practice and physicians need to think about how many additional patients they can actually accommodate, she said.

Another thing to keep in mind: Does the contract have an all-payer clause that requires your practice to accept exchange patients? When negotiating rates, be aware that many patients who gain coverage via the health insurance exchanges will have pent-up demand for health care because they have been uninsured or underinsured, Ms. McNeil advised. Their care could be more complex and time consuming, so doctors will want to be sure that reimbursement rates are adequate to cover this care.

Lawrence Kosinski, M.D., MBA, AGAF, chair of the AGA Institute Practice Management and Economics Committee, said: "The health insurance exchanges created in the ACA will have very significant financial consequences for our practices. It’s time for all of us to become knowledgeable of their ramifications."

On Twitter @aliciaault

SAN FRANCISCO – Stand by for some unexpected and potentially nasty surprises when the health insurance exchanges start up in 2014.

The exchanges will start enrolling patients this fall and begin sending information to patients and physicians this summer. Health insurers will begin sending new contracts to physicians around then too.

But there’s information available now that should send shivers up physicians’ spines, Elizabeth McNeil, vice president of the center for federal government relations at the California Medical Association, said at the annual meeting of the American College of Physicians.

A little-noticed provision of the Affordable Care Act gives exchange participants a 90-day grace period to pay their premiums. This was designed to provide a cushion for people who might not be used to paying health insurance premiums. Insurers have to pay all claims incurred by the patient in the first month, but in the second month, if the patient is still delinquent, all claims can be held as pending. By the third month, if the patient still has not paid, the insurer can terminate him or her.

The physician then has to collect payment for all outstanding claims from the patient. "This is going to put you at a lot of risk," Ms. McNeil said. "You’re going to have to be very vigilant with the exchange patients in watching what’s going on."

Many patients who’ll get coverage through the health insurance exchanges will also have much larger out-of-pocket costs than they are used to paying, Ms. McNeil said. In California, the CMA estimates an individual could face as much as $6,400 in uncovered expenses, and a family, up to $12,800.

Physicians also will need to pay attention to the contracts they sign with health insurers participating in the exchanges. The exchange could bring a large number of new patients to the practice and physicians need to think about how many additional patients they can actually accommodate, she said.

Another thing to keep in mind: Does the contract have an all-payer clause that requires your practice to accept exchange patients? When negotiating rates, be aware that many patients who gain coverage via the health insurance exchanges will have pent-up demand for health care because they have been uninsured or underinsured, Ms. McNeil advised. Their care could be more complex and time consuming, so doctors will want to be sure that reimbursement rates are adequate to cover this care.

Lawrence Kosinski, M.D., MBA, AGAF, chair of the AGA Institute Practice Management and Economics Committee, said: "The health insurance exchanges created in the ACA will have very significant financial consequences for our practices. It’s time for all of us to become knowledgeable of their ramifications."

On Twitter @aliciaault