The final rules for the formation and procedures related to health exchanges are rolling in. Doing research into laws gives me a head ache.
Are you ready to start reviewing contracts presented by Qualified Health Programs (QHPS)? Do you even have a clue what a health exchange is going to look or act like?
There remains latitude in how the plans can be presented, advertised and contracted with health care providers. A final ruling that will present a challenge to providers of health care involves the 90 day grace period the insured receive associated with non-payment of health insurance premiums.
Under the final ruling QHP’s are required to pay for services provided up to 30 days after the commencement of a non-payment. To protect the interests of the QHP’s and of the insured services provided in the 31st -90th day could be held and marked as pending. If the insured fails to bring his account to full status by the 90th day of the grace period his policy may be terminated. At that point all pending claims can be denied.
This scenario only applies to those individual insured who received advance payment of the premium tax credit. It should also be noted that QHP’s are given the option to not pay for services provided between the 30th-90th day of non-payment. If they are moved by the largeness of their heart they can pay all 90 days of claims. Raise your hands if you think this is going to happen.
This ruling leaves providers open to potential debt and fees associated with collecting those debts.
It also raises questions in my mind.
When a provider is notified that all payments are pending, can a provider require cash payment in advance prior to providing services? What about elective procedures? Can the provider decline to provide non-essential services? I don’t have the answer to these questions.
If you have any advice or expertise it would be appreciated.
Below is a quotation from the federal register of 5/27/2012.
You can also follow this link and look for page 18394
“Comment: Several commenters requested clarification regarding how the grace period for non-payment of premiums would work for individuals receiving advance payments of the premium tax credit and whether these policies differ for those who are not. Response: We clarify in §155.430(b)(2)(ii)(A) and (B) of this final rule that the grace periods for nonpayment of premiums are not the same for individuals receiving advance payments of the premium tax credit and other enrollees. The 90-day grace period for non-payment of premiums for individuals receiving advance payments of the premium tax credit is addressed in §156.270(d). In §155.430(d)(5) of the final rule, we clarify that the last day of coverage for individuals not receiving advance payments of the premium tax credit should be consistent with existing State laws regarding grace periods for non-payment.”
A study conducted in 2006 published in HEALTH AFFAIRS estimated that the average medical practice spends over $68,000 communicating with insurance companies. This figure did not include the cost to communicate with Medicare. Another study published in HEALTH AFFAIRS in 2011 suggested a figure of almost $80,000. This suggests that physician practices in the United States spend 30-35 billion dollars per year communicating with insurers. This number does not include the costs of communicating with Medicare. To some this sounds outrageous. I agree it sounds outrageous. Unfortunately to physicians and their practices it is fact. It hits home to their bottom line, their time management, their practice satisfaction and the overall health of their patients. . How much cost is there in faxes, telephone calls, data and chart review to complete prior authorizations for medications, and procedure requests? How much does it cost to pay billing and coding specialists to review our charts? What about referrals for tests, specialty care, and procedures. As primary care providers we are often required to fill out prior authorizations for tests that specialists order. How did we get into this mess? In my office a part time administrative assistant specializes in prior authorizations and referrals. How about the time spent by nursing staff completing the forms and then they must be reviewed, signed and returned. Any employer knows the hourly cost of an employee is not just their hourly rate. Workers compensation, health insurance, SSI, Medicare, and other expenses add to this cost.
Following are some examples of the burden a physicians office faces. These examples occurred in my office in just the past month. We received a prior authorization request for a medication. Information was returned. The next day we received a fax that more information was required. This fax was time stamped at 7:00 am. The information was required by 9:00 am, the same day to be valid. Nobody in the office read the fax until after 9:00 am. Because of this the entire process started again with another form being completed. Does that sound outrageous? I recently completed a 4 page prior authorization for a medication my 87 year old patient had been on for 20 years without event. It was denied and I needed to schedule an office visit and change the medication. Does that sound outragous? We received prior authorization requests for generic blood pressure medication because the preferred medication was another generic. Both medications are on the Walmart 4 dollar list. Does that sound outrageous?
We have computer access interfaces that allow this to take place in real time and sometimes rapidly. However, how many times do prior authorizations for studies get refuted and go to peer review? Far too often. With the case number in my hand I call insurance companies to wrangle with their hired gun, supposedly, a practicing primary care provider. I make the call myself. I listen to the computer telling me what options to select. I even wait to listen to them all because their “menu has recently changed”. After holding the minimum required time of “eternity” I finally get to speak to someone. Now, this person is not my peer. They are not a primary care provider. They are not a nurse. They ask me the same questions that my secretary filled out on the computer interface based on my chart. Funny thing though. They give me an approval number. Spending 15 to 30 minutes on the phone I gain approval for the procedure. Playing this game for 22 years I actually spoke with a peer, a primary care provider, on two occasions.
It takes me 30 seconds to refer the patient to specialist. This specialist will order the same tests, often come to the same conclusions and treatment decisions. Unfortunately this will result in a delay to the patients treatment. This will take more time from their busy life. This will require another day off from work. From a business standpoint what decision makes sense? From our patients standpoint, what decision makes sense?
There has to be a better way of doing this.
The American Medical Association offers sample insurance contracts and advice to its members to help negotiate contracts with insurance companies. There are consulting firms who are willing to provide advice for a fee. It is against antitrust laws for physicians to group together and discuss or set prices for fee for services unless they are completly merged. Independant Practice Associations (IPA’s) and Clinical Integrated Physician Networks can negotiate with Health Mantenance Organizations and insurance companies where “financial risk” is involved. I think there must be a central location where physicians and medical offices can go to find information concerning insurance company negotiations and let their voices be heard without breaking the law.
Are you chasing the carrot? Have you gotten a nibble yet? Pay for performance continues to grow as a policy, with little evidence supporting that it works. Many of my colleagues feel frustrated over the current methodology of pay for performance (P4P) programs. Each insurance company seems to have its own P4P program. Difficulty incorporating EHR systems into compliant reports causes time consuming hand written or hand entered report generation and increased expense for added ancillary staff. Add to this that the rules change frequently and the carrot never gets any closer is leading me to wonder if it is worth the effort.
There have also been several studies that I have read over the past several weeks that show that it is becoming common practice for some physicians to discharge patients from their practice for noncompliance in receiving recommended cancer screening tests or if they have complex medical conditions that make it difficult to get their vital signs or labs to meet guidelines (so called gaming the system). With more than 30 million more Americans expected to have health insurance in the future, how much more gaming of the system will occur. Is this good for patient care?
If after several attempts at compliance with preventive services fail, I grovel, letting my patients know that my reimbursement from their insurance is adversely effected. In effect, if they are not going to do it for themselves or their families, would they do it for me? I have not studied the response to this or how often I have done this but anecdotally it works. This is certainly a shift in my norm of practicing preventive care for the past 20 plus years.
One quality factor that is especially low in some primary care offices is the child and adolescent annual physicals. Some practices now offer incentives this group of patients. “Get your physical and have a chance to win a gift card for downloading music to your MP3 player.” Now were dangling a carrot in front of our patients so we can get a bigger carrot.
It is also apparent that primary care providers are affected much more by P4P programs then other specialties. When our office provides primary care services to a diabetic patient who follows with endocrinology there is no way to remove them from the panel that we are responsible for. If their hemoglobin A1C is not to goal, our fault. If they see a cardiologist who feels that a BP of 140/90 is ok for a diabetic and stops there medicine, our fault. If their cardiologist or endocrinologist is happy with an LDL of 150 and decreases their statin, our fault. So how long will we chase the carrot.