Doctors Seek CMS Help on ACA Insurer Rule that Puts Practices at Risk

Current requirements for when insurers must tell physician practices that a patient’s Patient Protection and Affordable Care Act (ACA) insurance exchange purchased health plan is in danger of being cancelled could leave physicians unreimbursed for their services warned more than 80 state and national organizations in a letter to Centers for Medicare and Medicaid Services (CMS) Administrator Marilyn Tavenner.

At issue is a complicated set of CMS directions to insurers about what they need to do when a plan member fails to pay his or her monthly premium for a plan purchased on an ACA insurance exchange. When this happens, the plan enters a 90-day grace period instead of being immediately cancelled. The insurer is responsible for the cost of treatments and services the patient may obtain during the first 30 days of the 90-day grace period, but after that time, the patient is responsible for paying for any care received.

The problem, according to the letter, is that current regulations do not require insurers to alert health care providers that a patient has stopped paying his or her premiums and entered the grace period. By the time health care providers must be alerted, the first 30 days of the grace period have already elapsed and payment for any care provided beyond that period must be collected directly from the patient.

Patient collection is a more costly process and, considering that the health care providers would be attempting to collect from a group of patients who’ve already opted to stop paying on their insurance plan, is likely to lead to non-payment and referral to a collection agency.

“By allowing issuers to “pend” claims during months two and three of the grace period, rather than being responsible for claims incurred during the entire three-month grace period as CMS had originally proposed, CMS has unfairly shifted the burden and risk of potential loss for patient non-payment of premiums to physicians. This financial burden will be untenable for many physicians,” the letter warned.

The signers of the letter, which include the American Medical Association and the Medical Group Management Association, specifically want CMS to require issuers to provide grace period information as soon as a patient enters the first month of the grace period. They also want CMS to require insurers to inform providers as part of the insurance verification process and by phone and website tools the insurer may also offer for insurance verification.

Read the letter here.