When patient doesn’t pay health exchange premium, you may be left holding the bag

September 3rd, 2014 - Scott Kraft
Categories:   Accounts Receivable|Payments   Collections   Denials & Denial Management  
0 Votes - Sign in to vote or comment.

One of the issues surrounding implementation of the Affordable Care Act (ACA) that impacts physician billing and payment and hasn’t gotten a lot of attention is what happens when a patient buys an insurance plan under the exchange, but then stops paying the premium.

The answer may end up leaving more than a few physician practices fuming over providing free care with little or no recourse.

First, patients have a 90-day grace period to get caught up on their premiums when they are receiving advance tax credits to help pay the premiums. A large number of exchange enrollees will be getting at least some premium assistance.

As a result, patients in this grace period will appear to still have coverage, because they will still have coverage. The final rule published in the Federal Register by CMS on March 27, 2012, establishing the rules and regulations governing the exchanges interprets the ACA to provide the grace period.

During the first 30 days of the grace period, the patient’s chosen insurance company is on the hook for paying any claims incurred by the patient. For the next 60 days, it is the service provider who will either have those payments suspended until the patient gets caught up, or have those payments recouped once the patient’s policy is canceled for the 90-day delinquency.

The objection from health providers is the same one you’re probably having – the lack of information about the patient’s insurance status could result in your practice providing costly services during the 60-day grace period and ultimately not being paid for the work.

The best way for you to figure out if a patient is in the grace period and at risk of having his or her policy canceled is to pay close attention to the claims remittance advice you get for unpaid claims during 2014, though in doing so at least one service will be potentially unpaid.

Insurers are allowed – but not required – to pend payments during the second and third months of the grace period to avoid the liability for patients whose policies are ultimately canceled.

Look for Claim Adjustment Reason Code 257, created on Nov. 1, 2013. The code descriptor is “The disposition of the claim/service is pending during the premium payment grace period, per Health Insurance Exchange requirements.”

Seeing that code is a sure sign that you’re at risk of losing money for that patient, and should consider seeing that patient only on an emergency basis until the premium is caught up or the policy is canceled.

It wouldn’t be advisable to tell the patient you know that he or she is delinquent on premium payments, but you can ask the patient to check with the insurance company to verify the status of his or her coverage prior to being seen.

It’s a small measure, but it’s the best one you may have to guard against providing a large volume of care and getting stuck with the bill. You are allowed to back bill the patients directly when policies are canceled for non-payment, though your chances of getting paid are probably remote.


###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

A Step by Step Guide to Medical Billing
August 20th, 2019 - Christine Taxin
The next 4 weeks we will be providing you with a step by step guide to why medical billing is now part of our Dental future. Dental surgery is performed to treat various conditions of the teeth, jaws, and gums. Surgical procedures that dentists perform include dental implants, treatment for temporomandibular ...
Are You Aware of Medicare Advantage Plans Timely Filing Rules?
August 20th, 2019 - Aimee Wilcox
The Medicare Fee for Service (FFS) program (Traditional or Original Medicare) has a timely filing requirement; a clean claim for services rendered must be received within one year of the date of service or risk payment denial. As any company who has billed Medicare services can attest, the one-year timely filing ...
Understanding Payment Indicators
August 19th, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Understanding how payment works with Medicare payment indicators and the impact a modifier has on payment is vital to pricing. Even if you are not billing Medicare, most carriers follow Medicare's policies for participating and non-participating rules.  Here is an article from Regence on their policy statement, describing the rules ...
Medical ID Theft
August 16th, 2019 - Namas
Medical ID Theft "So, do you guys think you can do something with that?" John asked angrily at our first meeting with him in August 2017 as he slammed a stack of medical bills, EOBs and collection letters - three inches high - down in front of my partner and I. ...
Healthcare Common Procedure Coding System (HCPCS)
August 13th, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
There are three main code sets and Healthcare Common Procedure Coding System (HCPCS), is the third most common code set used. They are often called Level II codes and are used to report non-physician products supplies and procedures not found in CPT, such as ambulance services, DME, drugs, orthotics, supplies, ...
Q/A: I Billed 2 Units of L3020 and Claim was Denied. Why?
August 13th, 2019 - Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA
Question: We billed 2 units of L3020 but were denied for not using the right modifiers. What should we do? Answer: Rather than submitting two units of the L3020 to indicate that the patient one orthotic for each foot, you would need to use modifiers identifying left foot and right foot. Appropriate coding ...
Will Medicare Change Their Rules Regarding Coverage of Services Provided by a Chiropractor?
August 13th, 2019 - Wyn Staheli, Director of Research
Two separate pieces of legislation introduced in the House of Representatives (H.R. 2883 and H.R. 3654) have the potential to change some of Medicare’s policies regarding doctors of chiropractic. Find out what these two bills are all about and how they could affect Medicare policies.



About Codapedia by InnoviHealth Systems Contact Us Terms of Use Privacy Policy Advertise with Us

Codapedia™ by InnoviHealth Systems™ - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain) - Fax (801) 770-4428

Copyright © 2009-2019 Find A Code, LLC - CPT® copyright American Medical Association