Exchange Plans Create Eligibility Verification Nightmare

As if verifying insurance benefits wasn’t already enough of a hassle for practices, they now face new challenges with patients enrolled in exchange health plans. Provisions in the law allowing for payment grace periods on exchange plans are creating unprecedented barriers to eligibility verification – a practice manager’s worst nightmare.

In addition to the standard verification process, practices now also need to verify whether or not a patient has in fact paid their premiums.  This additional layer of verification is necessary as a result of a provision of the Affordable Care Act which offers exchange patients a “grace period” of up to 90 days to pay their premiums before the plan will be cancelled. Insurers are still required to pay on claims made within the first 30 days, but nothing is guaranteed on the last 60 days. Claims made during that 60 day period are pended and eventually rejected if premiums aren’t paid by the patient.

Sheila Lawless, Office Manager of a small rheumatology practice in Wichita Falls, Texas told PBS News Hour about her office’s struggles with verifying exchange plans. “We’ve been on hold for an hour, an hour and 20, an hour and 45, been disconnected, have to call back again and repeat the process,” Lawless explains.

According to Lawless, these wait times are in addition to the administrative time spent verifying all non-exchange plan patients. “Most small practices run lean and mean — you’ve got one or two people to do this process plus do their other job duties that day as well, which is tend to the patients in front of them,” Lawless says. Even with just a “trickle of exchange patients” she tells PBS the practice has incurred more overtime expenses and higher overhead costs overall.

And this is only the beginning, as more Americans enroll in exchange plans and seek coverage, more and more office managers will find themselves in the same boat as Lawless.

Unfortunately, practices aren’t the only ones feeling the effects of this ill-prepared system. A January New York Times Article tells disturbing stories of patients forced to pay out of pocket after their Providers were unsuccessful at verifying their exchange plan eligibility.

“In Los Angeles, Hilary Danailova, who is almost eight months pregnant, said she had to pay $630 for an ultrasound on Thursday after failing to get an ID card or any confirmation of coverage from her new insurer, Anthem Blue Cross. Ms. Danailova, 38, said she signed up just before Christmas and sent her first month’s premium of $410 by overnight mail on Jan. 3. She has repeatedly tried to reach Anthem to see whether the company has processed her payment.” 

Dr. Curtis Miyamoto, a Radiation Oncologist at Temple University Hospital and President of the Philadelphia County Medical Society tells the New York Times, “The system wasn’t really built to handle this kind of glut of new patients, so it’s resulting in us having some delays in getting people verified, and therefore delays in their care.”

Has your office experienced difficulty verifying exchange plans? Had any luck finding any alternative solutions to verification of these types of plans? We want to hear your feedback, leave us a comment below or email us at info@ntctexas.com.