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Tuesday, March 25, 2014

How to Navigate the Bumpy Road Ahead with the New Health Insurance Marketplace

By Orly Avitzur, MD, MBA, FAAN

The patient who came to my practice looked like a typical HMO patient. Her insurer was a small regional company for 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. 

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? Find out in our April 17 issue of Neurology Today. See our previous coverage of neurology practice changes:

     Neurologists, what has been your experience with the Affordable Care Act health insurance exchanges? Good or bad, we want to hear from you — what the challenges have been and how you’re dealing with them. Share your story for possible publication by emailing