Practice Economics

ACA exchange plans present reimbursement challenges


Physicians face a number of new hurdles in getting paid for the care they provide to patients covered by the Affordable Care Act’s health care marketplace plans.

Texas physicians are reporting difficulties in getting information on patients’ coverage from exchange plans, as well as a lack of understanding from patients about their coverage and financial responsibilities, according to Dr. Austin King, president of the Texas Medical Association and an otolaryngologist in Abilene.

Dr. Austin King

Without this information, it is difficult to have a clear conversation about what patients will owe out of pocket, Dr. King said, adding that patients have a steep learning curve when it comes to the marketplace plans. "It’s a matter of educating patients as to what to expect from these policies."

Another looming problem: The 90-day "grace period" for plan members who have not paid their premiums. During the first 30 days of the grace period, plans must pay claims, but for the next 60 days, they can withhold payment, and if a policy is canceled because of nonpayment of premiums, plans are not required to pay physicians for claims.

Dr. King noted that in Texas, some plans are refusing to pay claims in that 60-day period. However, the single statewide carrier, a Blue Cross Blue Shield plan, is paying claims during the final 60 days of the grace period, but will seek to recoup payments made to physicians if coverage is canceled because of premium nonpayment.

The severity of this problem is not yet known, Dr. King said, but "it will be interesting to see how this impacts the bottom line," particularly for primary care doctors, who he expects to be more severely impacted than specialists.

Dr. King’s observations mirror the results of a recent survey by the Medical Group Management Association.

More than half (60%) of respondents to an April survey said that they believe that the ACA marketplaces will have a "very unfavorable" or "unfavorable" impact on their practices. Nearly 94% have seen patients with marketplace coverage.

Half of respondents said that payment rates offered by the marketplace plans are either "much lower" or "somewhat lower" than those offered by traditional commercial contracts. A little less than half (46%) said the rates are "much lower" or "somewhat lower" than other traditional products offered by the same payer.

The majority of respondents reported having a "somewhat more difficult" or "much more difficult" experience with marketplace plans in verifying patient eligibility (63%), obtaining cost-sharing information (62%), and obtaining provider network information to facilitate referrals (57%).

It is that difficulty in obtaining information that is driving the dissatisfaction in dealing with ACA marketplace plans, said Anders Gilberg, senior vice president of government affairs at MGMA. He added that practices are hiring staff just to deal with getting information from exchange plans.

The MGMA survey gleaned responses from 728 medical groups composed of more than 40,000 physicians nationwide.

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