Healthcare Law Blog

Physicians: Have You Checked Your Numbers?

As promised, the Centers for Medicare and Medicaid Services released information about Medicare payment to physicians and certain health care professionals on April 9^th. The release is in conjunction with the policy change instituted by the U.S. Department of Health and Human Services, which allows CMS to respond on a case-by-case basis to Freedom of Information Act requests for Medicare payment information related to individual physicians (see more on the topic here). More >

Part II: Understanding All-Payer Claims Databases

Earlier this week, we discussed the benefits of all-payer claims database (“APCD”) systems. Nine states currently have APCDs in place, but Kentucky is not one of them. These systems provide a multitude of information on the cost, use, and quality of health care in a given state, but the question remains: how do providers feel about APCDs? More >

Part I: Understanding All-Payer Claims Databases

Over the last decade, many states have established all-payer claims database (“APCD”) systems that collect medical, pharmaceutical, and dental eligibility and claims information. Payers, including insurance providers, third-party administrators, prescription drug plans, Medicaid, and Medicare, are responsible for depositing eligibility and claims data into a collective system. The data can then be used to generate important information about cost and quality of care. By gathering detailed information in one place, a statewide picture emerges – information on service providers, patient demographics, and other important healthcare data. More >

The ACA Loophole Of Which Providers Should Be Aware, Part II

Earlier this week, we discussed the three-month grace period afforded to enrollees of qualified health plans (“QHPs”). To recap that article, the ACA requires that QHPs pay claims for the first thirty days of the grace period during which premium payment remains unpaid, but issuers may pend claims for the final sixty days of the grace period. If the balance remains unpaid, the issuer may deny any claims submitted within the final sixty days. More >

The ACA Loophole Of Which Providers Should Be Aware

Providers contracting with state health insurance exchanges may find themselves shortchanged for services provided due to a little-known loophole in the Affordable Care Act (“ACA”).

Under the ACA, an individual who fails to pay his or her insurance premiums has a three-month grace period before the policy is cancelled. Insurers, however, are only responsible for paying claims during the first month of that grace period. The ACA will allow exchange plan, also known as “qualified health plan” (“QHP”), issuers to pend claims submitted by providers during the last two months of a federally subsidized patient’s three-month grace period for premium payment delinquency. If the patient is terminated at the end of the three months, the QHP is free to deny all claims submitted for that patient within the final two months.

Here’s what providers can expect during the three-month grace period:

First month of delinquency:

• Claims are paid normally. The QHP treats this month as paid even if the enrollee is eventually terminated for non-payment.
• Providers are not notified of the patient’s delinquency.

Second and third months of delinquency:

• The QHP has the option to pend claims for services performed until the enrollee pays his or her outstanding premium balance.
• Providers submitting claims during these two months are notified of the potential that claims submitted for services performed for the enrollee may be denied.
• If the enrollee pays off the premium balance, providers’ claims are paid at that time.

Terminated after three months of delinquency:

• The QHP has the option to deny all claims for services performed in the second and third months of delinquency.

Note that the timing of an enrollee’s grace period is based upon the date when a service was rendered, not the date of claim submission. In fact, a patient may enroll in a different QHP during the next open enrollment period regardless of whether they have paid off an outstanding premium balance with their previous insurer.

Providers have the option to seek payment from the patient for denied claims, but a patient who is unable to pay their insurance premium is also unlikely able to pay a provider’s bill. Further, the legal action necessary to recover payment is a costly endeavor for any provider. Check back on Thursday for more information on this topic.

Services may be performed by others.

This article does not constitute legal advice.