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The ISMA offers tips to help you manage federal marketplace patients
e-Reports, July 14, 2014
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If you are seeing just a few patients enrolled in the federal exchanges, you are not alone. Most physician offices are reporting that patient volume or loss due to the Affordable Care Act (ACA) has not yet been significant. Patients are still learning if their doctors and local hospitals are in their new networks. However, some practices have told the ISMA about challenges associated with the exchanges.

In-office education
Some patients who may now have insurance for the first time are unfamiliar with terminology, such as co-pay or co-insurance. Office staffs also are explaining the health plan coverage, along with teaching patients how to read the insurance card.

“We do a lot of patient education at the window,” said Nancy Bolds, practice manager for Elwood Family Medicine. “The process has been very confusing for us and for patients. But all in all, it’s working out.”

Bolds explained that in January, many patients did not have their cards. Her current challenge is figuring out patient networks.

Dr. Duplantier
Billing manager Andrea Stewart and John Duplantier, M.D., review patient records.

Marketplace insurance cards
Most of the issues with marketplace insurance cards center on the prefix, according to Gloria Kirkham, CPC, CPC-I, COBGC, ISMA practice advisor.

“Practices are struggling with the prefix on the patient cards,” she explained. “Many of the cards look alike, such as Anthem and the Anthem Marketplace plan, so be aware of the differences in cards. The prefix identifies the plan.”

The problem is further exacerbated when out-of-state patients come to Indiana and seek medical care.

“There is a learning curve right now. Each state has different plans,” said Kirkham. “It’s important to get the identification number on the card and verify coverage with the plan. Precertification is vital for reimbursement.”

She also noted that patients often do not throw away old insurance cards and confuse them with the newly issued ones.

Columbus physician David Rau, M.D., has been challenged with verifying coverage for couples named on one card.

“The only problem that we have experienced was trying to verify coverage for a husband and wife that shared a card. Both patients are listed on the card together, but we could only get verification for the husband. We have since gone back to verify the wife’s coverage and she now appears on the website,” said Dr. Rau.

Billing and premiums
Billing for exchange services can be problematic if patients are not current with their premiums. Non-subsidized patients have a 30-day window to pay their premiums; subsidized patients have a 90-day window.

“During that time, insurance companies can pend the claim until the premium is paid,” said Kirkham. “If the premium is not paid, the doctor must collect from the patient for the services rendered.”

Andrea Stewart, billing manager for Central Indiana Allergy in Indianapolis, said her practice requires patients to sign a self-pay form. “The form states that we collect at the time of service if their premium is not current,” she said. “If they do not sign the form, we do not see those patients.”

To reduce problems, Kirkham advises that you:

  • Become familiar with the marketplace plans.
  • Call the plan at each patient visit for prior authorization or verification.
  • For help, call your plan representatives or the ISMA at (800) 257-5762 or (317) 261-2060.
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