Contributed by Bonny L Brill, CMRS

Twenty-eight year old Jacob, a small business owner, had a follow-up appointment with his regular primary care/internal medicine doctor last month. It’s the same physician Jacob has been going to for his Crohn’s disease for several years. At check-in Jacob presented his new insurance card from a major insurer, a card that looked like any other, so all seemed fine. Doctor Smith (fictitious name, as is Jacob’s) spent considerable time with Jacob, ordered an important outpatient procedure and coded the visit appropriately as 99215 (40 minute office visit).

With phones constantly ringing, patients streaming in every ten minutes and the schedule in constant flux, Dr. Smith’s one-person front desk does not have time to confirm insurance eligibility prior to each visit. This is not uncommon for one-doctor practices like his. It hasn’t been an issue in the years I’ve worked with him as an independent medical biller.

This time it was different for both patient and doctor. Jacob and his expectant wife had recently enrolled in an Affordable Care Act (ACA) medical insurance exchange plan. They pay $700 in monthly premiums and can choose their doctors, or so they thought. Jacob did not realize they were instead enrolled in an HMO plan with a very limited network. They were assigned a newly licensed D.O. as their primary care physician, someone they have never met and whose office is a forty-minute drive. Prior authorizations and in-network referrals are always required. Since then, Jacob has been put on lengthy holds by the insurance company with no resolve. Eventually his situation will get “fixed,” but at unexpected costs. His claim was denied and either 1) Jacob has to pay the doctor’s bill out of pocket now, or 2) Dr. Smith has to wait and hope insurance eventually pays. Jacob’s wife recently had an ultrasound, and presumably that claim is in limbo, too.

Doctors naturally want to care for their patients, but from a cash flow perspective a physician cannot be their patients’ banker if they hope to have a financially healthy practice. That is why we stress financial policy agreements that put patients responsible for balances not paid by insurance within sixty days. All patients (yes, all patients) need to sign the agreement. In this case, Dr. Smith also has a credit card of file (CCOF) system, and Jacob’s credit card was charged for the office visit.

Would it have made a difference if Dr. Smith’s office had checked insurance eligibility beforehand, or at least upon Jacob’s check-in for his appointment? Perhaps so because Jacob could have had the option of rescheduling the appointment. But for exchange policies, the quick, online verification system medical offices and billing services use is not an option. Verification requires a call to the insurance company. Colleagues tell me they have had to spend over an hour waiting on the phone, been disconnected and had to call back. I have, too, which leads us back to cash flow management. For many physicians it is not practical or an affordable use of time or resources to confirm insurance eligibility of each exchange patient prior to service.

People who enrolled in ACA medical insurance plans are beginning to use them. This is very good news; they have access to and are receiving the quality health care they need. For providers, however, the road to reimbursement is bumpy. The reality is that if we accept ACA exchange insurance we need to understand ways to get paid promptly.

If you have question about how the Affordable Care Act can impact your practice, call us today at 303.835.7992.