Doc insurance exchange worries: Premium nonpayment, low reimbursement


Doctors want to require health insurers to notify them when patients haven't paid their premiums, given the Affordable Care Act provides consumers with 90 days to go without paying their premiums and not lose coverage, MedPage Today reported.

Under the ACA, health insurers selling exchange plans must give consumers a 90-day grace period before ending coverage for not paying their premiums. Moreover, insurers don't have to process claims on patients who haven't paid their premiums during the grace period, according to a KevinMD blog post. Doctors, however, must still provide care during the three months of nonpayment.

So the American Medical Association's House of Delegates adopted a new policy that proposes insurers must inform physicians when their patients enter that grace period, according to MedPage. Insurers that don't notify physicians would face a binding eligibility determination that would make them responsible for claims made during the grace period.

Insurers already give docs real-time verification of patient-subsidy eligibility, co-payments, deductible information and claims processing, according to AMA policy, MedPage Today noted.

In addition to grace-period concerns, doctors also are complaining that exchange plans will pay them less, according to Kaiser Health News.

About 40 percent of more than 400 physicians surveyed by the Medical Society of the State of New York said they opted out of exchange participation. And while two-thirds of the respondents said they received no information about reimbursements, a significant majority of those physicians who did reported reimbursement rates well below what the insurer pays in other contracts, KHN reported.

Insurers admit to rate reductions in some exchange plans but note that physicians will offset less pay by seeing more patients in the smaller exchange networks. By offering plans with smaller provider networks, Blue Cross and Blue Shield of Illinois, for instance, can offer premiums 20 percent to 30 percent lower than its other plans, FierceHealthPayer previously reported.

"We're not motivated to gouge the doctor," Blue Cross Blue Shield Association Executive Director for State Affairs Kim Holland told KHN. "We depend on good relationships with quality physicians. ... I can't imagine any product we offer is going to have a physician rate that would discourage them from seeing a patient," she said.

For more:
- read the MedPage article
- check out the KevinMD post
- here's the KHN article

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