Insurance Exchanges: 6 Crucial Questions for Physicians

Deborah Walker Keegan, PhD; Elizabeth Woodcock, MBA


October 15, 2013

In This Article

A New World of Health Insurance

The insurance exchanges opened for business on October 1, 2013. The country is focused on the offerings and mechanics of these one-stop shopping markets for health insurance, with analysts engrossed in projecting enrollment data.

But missing from the current dialogue is any discussion about the impact of the exchanges on caregivers -- namely, you. Physicians are naturally wondering, "How will the insurance exchanges affect me and my practice?"

The answer isn't simple; indeed, there are 6 crucial questions to resolve in order to prepare for the January 1, 2014 initiation of the plans purchased on the insurance exchanges. As you consider these questions, it is readily apparent that changes to your workflow, and perhaps payer contracts, may be necessary to survive and thrive.

1. Do I Have Contracts With the Exchange Payers?

To determine if you are contracted with an exchange payer, access the information via your state's exchange Website or insurance commissioner. Make a list of all of the payers that are offering plans and the type of plans they are offering. (Some states allow payers to offer some products in certain markets but not others, so be sure to take that into consideration.)

If you are not contracted with a payer offering health plans on your state's exchange and are looking to grow your practice, set up a meeting with the payer to explore your contract options. You can learn more about the exchange in your state from the State Health Exchange Market Profiles.

2. How Much Will I Get Paid?

If you are contracted with the exchange payers, determine the payment amount you will receive. Some of the payers are not altering the reimbursement terms of existing contracts with physicians, but others are sending contract addendums to attempt to change the payer terms to correspond with the Bronze, Silver, Gold, and/or Platinum offerings they have placed on the exchange.

Be on the lookout for any communication from your payers related to payment terms and conditions. Moreover, prepare to renegotiate with the payer and/or discontinue participation with the payer if the terms are not acceptable to you and your practice.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: