Many items in the affordable care act are going to require changes in office policy. This letter from MGMA to CMS underlines one of the issues as yet unresolved which may impact the office operations. Making certain that there is a mechanism in place for determining that insurance coverage is still valid, including questioning the patient regularly, as well is communicating with the insurance carrier will increase the likelihood of timely payment, and in the case of cancellations of policies, payment at all.
In a recent letter to Centers for Medicare & Medicaid Services (CMS), MGMA raised concerns about a provision in federal regulations that puts healthcare providers at risk of not being paid when patients are late paying their premiums. As part of the implementation of Affordable Care Act (ACA) health insurance exchanges, health insurers offering qualified health plans on the exchanges (issuers) must provide a three-month grace period to enrolled individuals who haven't paid their premiums. During the first 30 days, issuers must pay for claims, but in the last 60 days, they will hold claims. If the patient's coverage is cancelled after 90 days for failure to pay premiums, issuers are not required to pay any claims for services furnished in the last 60 days of the three-month grace period. Practices must then attempt to collect from the patient.
In the letter, MGMA urged CMS to specifically require issuers to provide grace period information during routine insurance eligibility verification requests. As part of a real-time eligibility verification request, it is essential for practices to have accurate, up-to-date information in order to work with patients and plan accordingly for potential financial liabilities associated with non-coverage.
Additionally, we called on CMS to require issuers to provide grace period information by at least day 15 of the 90-day grace period. Should an issuer not provide accurate information related to the grace period during an eligibility verification request, the issuer should be held financially liable for any services furnished during the last 60 days of the grace period for enrollees whose coverage is ultimately cancelled.