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Welcome to the New Health Insurance Marketplace

How to Navigate the Bumpy Road Ahead

Avitzur, Orly, MD, MBA, FAAN

doi: 10.1097/01.NT.0000446537.96162.3e
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Practice managers for neurology practices offer tips for addressing some of the reimbursement and billing challenges for patient referrals from the new health insurance exchanges.

The patient who came to my practice looked like a typical HMO patient. Her insurer was a small regional company with which my Westchester, NY, office performed telephonic verification of patient eligibility and benefits. The company's representative confirmed those details and provided us with information regarding the deductible (none) and co-payment ($45). When the patient arrived, her insurance card was viewed and copied, and appeared no different from the others we had seen for that payer.

When we followed those identical procedures for the patient's husband a week later, however, a different representative informed us that the coverage was actually provided by an exchange product, and one with which we did not participate. Furthermore, it was the same plan under which his wife had been covered, and there were no out-of-network benefits.

Not only had we not been told that the exchange product covered the first patient, but also the information we were originally provided about her coverage was incorrect. In fact, our claims would be denied.

We had anticipated such problems, but our usual processes failed nevertheless. What could we have done differently and what can you do to avoid a similar mistake? I asked two practice administrators and members of the AAN Medical Economics and Management (MEM) Committee for suggestions.

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William S. Henderson, a fellow of the American College of American Practice Executives and a practice administrator in the Division of Community Neurology at Albany Medical College, said: “You can never go by how the card looks; there are usually no identifiers on insurance cards to indicate that the patient is covered by an Affordable Care Act (ACA) plan.”

To avoid problems in the future, Henderson suggested that practices ask each insurer how to determine the status of their subscribers. He advised that all offices should “pre-qualify” their patients by checking their insurance coverage prior to service. Most practice management systems can get the data via a download in advance of the appointment, Henderson pointed out, and in cases where an insurer isn't tied to your clearinghouse — the intermediaries that forward your claims to insurers — you should check directly with the payer online. If you verify the card online at the insurer's website or via the electronic health record software interface that checks eligibility, it will tell you which plan the patient has, he said. “We take a screen shot of the website if there is any question,” he added.

David A. Evans, MBA, chief operating officer at Texas Neurology, which includes 17 providers, and chair of the Practice Management and Technology Subcommittee of MEM, added: “We've been able to identify many exchange products through their ID prefix and/or group numbers.”

But that's only one type of challenge that medical practices are facing as a result of the new Obamacare products. What other problems should you be on the lookout for and what can you do to avoid claim denials over the upcoming months as more patients covered by Obamacare products enter the marketplace?

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For starters, neurologists can learn more about the 90-day grace period that the ACA grants to individuals purchasing subsidized coverage through the state insurance exchanges. Neurology practices typically depend on online verification systems to ensure that patients are insured by confirming eligibility and benefits in advance of providing services as well as corroborating information about deductibles and co-pays. But for patients who receive an advance premium tax credit and do not have to pay their premiums in full there is a 90-day “grace period.” This means that practices also have to call (yes, by phone!) each insurer to make sure that the patients have paid their premiums. If that is not the case, the insurance company can refuse to pay for the visit or request that the payment is returned later. That's because a provision in the ACA law requires that insurers cover the first 30 days of treatment, but during the subsequent 60 days there are no guarantees. If a patient receives care during that period of time, the claim may be “pended” or delayed until premium payment has been ensured; if the payment has not been made, the coverage could be cancelled.

CNN Money polled insurers and reported on Jan. 31 that around one in five people who selected health insurance policies from the state and federal exchanges last year hadn't paid their first month's premiums. A CNBC story published March 14 provided equally ominous results: in Maryland, only 54 percent of enrollees paid for their first premiums as of March 1; exchanges operated by Washington and Vermont also failed to crack 60 percent for payments.

How do federal officials respond to these numbers? To date, they have yet to release enrollment data from the Obamacare marketplace that serves 34 states. So no one knows exactly how many enrollees nationwide have actually paid the first insurance premiums. [The Kaiser Family Foundation, however, has compiled statistics, through March 1, on the number of enrollees in the state exchanges and those who would be eligible through Medicaid and other forms of financial assistance: Also, see “Marketplace Enrollees.”]

While health insurers are required to notify physicians of patients' grace period status, questions concerning the specifics of notification, as well as other issues of concern to physicians, have yet to be addressed, according to the American Medical Association (AMA). A Feb. 25 report by the Henry J. Kaiser Family Foundation and National Public Radio indicated that call center telephone lines are inundated with queries and hold times are excessive, even by today's strained standards.

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Most doctors' offices, which have already trimmed staff and overhead costs in order to survive, will have little time to devote to this onerous and time-consuming task. Additional time will also need to be allocated for patient communication. Evans said his practice has begun to provide financial counseling to patients who are insured through exchange products prior to receiving services.



“It's advisable to post signs and include language about your practices' financial policies related to receiving services during the grace period,” said Evans. The AMA has sample language available for both of these areas, including other recommendations and resources for practices, he said. [See “Resources for Obamacare Products.”]

The AMA also recommends that physicians find out which reason and remark codes and associated terminology the health insurance issuer will include in its electronic remittance advice (the ASC X12 835 Health Care Claim Payment/Remittance Advice) to convey grace period information. For example, which codes and terminology, if any, will indicate that the patient is in the first month of the grace period, the second month of the grace period, or the third month of the grace period?

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Practices that are buying and billing for expensive drugs such as biologicals should verify benefits monthly and provide extra diligence when confirming that patients have paid their premiums, Evans suggested. “It would be a costly error to continue providing high-dollar services during the grace period,” he said, pointing out that practices may wish to consider restricting certain services during those 90 days. “If you choose to do so, verify that you will not violate any provider agreements or state laws,” he added.

“The reality is there is no real way to avoid potential losses,” said Henderson. “It's really too early to even address such issues since the exchanges are new — the ACA was only rolled out as of Jan. 1 and final patient enrollment for this year ended on March 31 — and we, as providers, don't have enough history with the products nor do the insurers.”

On March 5, the AMA and more than 80 groups, including the AAN, sent a letter — — urging the Centers for Medicare & Medicaid Services (CMS) to require insurers to notify physicians as soon as a patient who has purchased health insurance through an ACA exchange enters the grace period, recommending that this notification should be provided as part of the insurance eligibility verification process.

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Meanwhile, here are a few things you should know about the deductibles through the exchange. In 2014, there's a $6,350 maximum for individual out-of-pocket costs for in-network services. The maximum for families is $12,700. There are four types of plans: bronze, silver, gold, and platinum. (There are also catastrophic high-deductible plans available for people 30 years old and younger and people with financial hardship exemptions.)

According to, premiums are usually higher for plans that pay more out-of-pocket medical costs; for example, patients with Platinum plans will likely pay the highest monthly premiums, but will have lower out-of-pocket costs when they go to the doctor or use another medical service. Those with Bronze plans will likely have the lowest premiums among the metal tiers, but will be responsible for paying a higher share of costs when they get care. Clearly, higher deductibles will likely mean higher risk for physician practices, and that risk can translate to high financial losses.

Texas Neurology verifies how much of the deductible has been met and provides an estimate that patients should expect to pay at the time of service, but not all state exchanges are offering clear rules about collection.

“Our insurers have said that regardless of how we handle their other product lines — for example, collecting co-pays or deductibles — we are not to collect any payments from those with an ACA plan,” said Henderson. He told Neurology Today that the insurers are referring providers to their websites to find information on each patient deductible but are warning that the data may not be accurate for the purposes of collecting any patient payment at time of service.

“After the insurer processes the claim, they will tell us what to collect from a given patient,” he said. “The likelihood that a provider will not get paid for an ACA patient service at some point in the continuum of caring for that patient is great,” warned Henderson, explaining that this reality is a given based on the design of the ACA.

“At the present time, we don't see how we can recover payment from an ACA patient, after their first visit with us, should they choose to drop their coverage at some point.”

At press time, seven million people had signed up for Obamacare plans on the exchanges by the time the enrollment deadline ended on March 31. This program is in the early stage, but neurologists would do well to learn as much as they can in the meanwhile about navigating this new health model.

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Dr. Avitzur, an associate editor of Neurology Today and chair of the AAN Medical Economics and Management Committee, is a neurologist in private practice in Tarrytown, NY, who holds academic appointments at Yale University School of Medicine and New York Medical College.

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Good or bad, we want to hear from you about what your experience has been with handling patient referrals from the state and federal health insurance exchanges — what the challenges have been and how you're dealing with them. E-mail your story to



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A new toolkit is available at and includes the following:

  • “Step-by-step guide to the ACA ‘grace period’” outlines key questions to ask health insurers about how a physician practice will be notified of grace period status, physicians' rights with respect to payment and recoupment, and more.
  • “Grace period collections policy checklist” provides help to physician practices for amending existing collections policies or creating new policies that anticipate and address potential grace period concerns.
  • “Model financial agreement language for patients receiving Advance Premium Tax Credits” provides language relating to the grace period that physicians may consider adding to their existing patient financial agreements.
  • “Sample letter: Grace period notice to patients” offers a template to provide to patients receiving an advance premium tax credit, explaining what the grace period is and what patients need to do if they are in the grace period.

VIDEOS ON DEMAND: How will the health insurance marketplace affect your neurology practice? Determining eligibility for services and deductibles could be confusing at first, says Elaine Jones, MD, FAAN, chair of the AAN Governmental Relations Committee, in this video interview. But Dr. Jones, who served on the on the advisory board for Rhode Island's health insurance exchange established a few years ago, notes that, depending on the state's exchange policy, neurologists should not expect things will be much different. She recommends that neurologists consult their state medical societies for help with answering questions about their state's exchanges. Watch the video here: For more AAN resources, visit



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•. CNN Money: Obamacare deadbeats: Some don't pay up,
    •. CNBC: All over the map: States ‘paid’ Obamacare rates,
      •. Neurology Today: What the new health reform law means for neurology,
        •. Neurology: Clinical Practice: Payment reform and the changing landscape in medical practice: Implications for neurologists,”
          •. Neurology: Clinical Practice: Supreme Court decision on the Affordable Care Act: What does it mean for neurology?
            © 2014 American Academy of Neurology