Insurance Exchanges: 6 Crucial Questions for Physicians

Deborah Walker Keegan, PhD; Elizabeth Woodcock, MBA


October 15, 2013

In This Article

Making Sure You Get Paid

3. How Should I Manage the "Grace Period"?

One of the biggest challenges for physicians will be the "grace period" that the exchange subscribers receive. The exchange plans permit a 90-day grace period for subscribers to pay their premium. For the first 0-30 days in the grace period, providers will be paid; however, for services provided in days 31-90 of the grace period, you may not be paid.

Furthermore, any payments that are paid to you during the 31- to 90-day period will likely be retracted by the payer at a later date. This leaves you with only one choice -- chase after your now-delinquent payment from the patient!

The Centers for Medicare & Medicaid Services has advised payers to notify physicians "as soon as practicable" when the patient has entered into the grace period. This edict has a nice ring to it, but it's a slippery slope.

Just imagine a patient who pays his or her premium in month 1, then does not pay in month 2, and then pays again in month 3. What is "practicable" in this scenario? You get the picture: The attempt during the grace period to determine a patient's premium payment status -- and the ensuing timeline to communicate with the treating physician -- are likely to be confusing at best.

Take the opportunity to:

Confirm that payers are complying with the HIPAA electronic standards, which require them to supply you with information about each patient's eligibility within 20 seconds of your request, and overnight for batch eligibility requests.

Conduct patient financial clearance on each patient and for each visit to learn the patient's premium payment status and out-of-pocket payment obligations.

If you determine that a patient is in the grace period, if your contracts permit, set up a formal financial meeting to determine if a waiver form or budget plan may be needed.

4. How Should I Manage a Large Volume of Patients With High-Deductible Health Plans?

A patient who is healthy with a high-deductible plan will essentially be a "self-pay" patient in your practice. (The Bronze plan will have a $5000 deductible and the Silver plan a $2000 one.) That is, the patient will be responsible for out-of-pocket payments up to the allowable -- the reimbursement you are allowed to collect, in accordance with the payer's fee schedule -- for the services you provide. In addition to the recommendations outlined above regarding patient financial clearance:

Review your contracts with payers to make sure you can collect patient out-of-pocket payments at the point of care. If not, negotiate to do it.

If you are able to collect patient financial responsibility at the point of care, capture all time-of-service payments due from the patient, to include copayments and deductibles. If your practice is not geared up to collect the actual deductible from patients, make sure you capture a "deposit" to the deductible -- provided your contracts permit you to do this at the point of care.

If your contracts permit, attempt to collect the patient out-of-pocket payment in advance of nonemergent, scheduled services. This will optimize revenue and reduce delays in cash flow.

Revisit your patient collections cycle. Instead of giving patients a generous timeline to pay their bills, such as via 5 statements, 2 letters, and 2 phone calls to every patient, consider reducing this to 2 statements, 1 final notice, and a corresponding telephone call, all processed within 75 days of the balance becoming due. This streamlined cycle reduces the time to payment and ensures that a significant portion of your revenue is not delayed. Plus, it's less costly for your practice to deploy.

Explore precollection vendors or outsourced partners in your market that can assist your own employees in managing patient receivables.


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