Contributed by Bonny L Brill, CMRS

I admit being relieved ICD-10 was postponed (again), and that Meaningful Use was, too. As a multi-practice medical reimbursement specialist, it has given me time to digest the latest laundry list of discontinued G codes and Correct Coding Initiatives (CCI) edits. This includes G8553, which was previously mandated by the government for its E-prescribing incentive. Providers had to report E-Rx on a percentage of their claims. Conversely providers that did not include G8553 E-prescribe during 2013 were caught off guard when they began seeing an additional two percent penalty beginning with their Jan 2014 Medicare reimbursements. Troubling is that CMS still includes E-Prescribe coding and billing instructions on its Web site (

My current cash flow concern is the 90-Day Grace Period associated with ACA (Obamacare) claims. It has been covered by healthcare publications and blogs, and strongly opposed by industry associations and leadership. But for providers, practice managers, and medical reimbursement specialists in the trenches, it has not gotten the attention it requires.

The Affordable Care Act 90-day “grace period” threatens the financial health of medical practices. It allows patients who have not paid their exchange premiums 90 days of continued coverage. Insurers are on the hook to pay providers for claims submitted the first 30 days, but services provided the following 60 days will be denied well after-the-fact. And payers can recapture any money paid to the provider. According to Jennifer Kowalski, vice president of Avalere Health, a practice consulting firm, the grace period option is afforded to 80 percent of exchange patients—those who are already receiving government subsidized coverage.

This places the burden of getting paid back on providers, and the reality is that collecting money from people already delinquent in paying their premiums will be difficult. This puts doctors at significant risk of not getting paid for services they provided.

Perfect Storm Cash Flow Scenario

“An individual purchases a health plan on the Exchange during open enrollment and receives a subsidy for a portion of their premiums. The member’s effective date is January 1, 2014, and the member pays their portion of the premium for the month of January. The member is now eligible for the three month grace period. The member does not pay their premium for the months of March, April, or May. Their three month grace period begins on March 1, 2014, and claims for dates of service within the month are processed by Anthem. Claims for dates of service on April 1 or after pend with a notification to the provider indicating that the member’s premiums are unpaid with the possibility of denied claims after the three month grace period (which ends May 31, 2014). At the end of the three month grace period, the member’s portion of the premium is still outstanding. The member’s health plan is terminated and claims for dates of service from April 1, 2014 through May 31, 2014, are denied. (Source: Health Insurance Exchange December 2013, Anthem Blue Cross and Blue Shield)

Herein lies the problem: If providers call provider customer service to verify eligibility, will the representative tell them a member is in the three month grace period? Yes, according to Anthem Blue Cross Blue Shield. But E-verification systems will likely not indicate so. It is my experience that ACA exchange policies are mostly not E-verifiable at this time. And practices do not have the time or resources for lengthy calls to payers to determine eligibility status of exchange policies. Medical practices rely on E-verification, and unfortunately often after services are rendered. Calling for a pre authorization?

Representatives will not provide that a patient is delinquent in paying their premiums, and certainly not that the doctor is at risk of not getting paid.
According to Elizabeth Woodcock, MBA, FACMPE, CPE, a recognized specialist in medical practice management, “Indeed there are problems…months later you’re left to chase after the money.” Her recommendation: Require proof of premium payment, and if not [make sure to] require deposit down for today’s visit. (Revenue Opportunity: Creating Success for Your Practice, in a Webinar sponsored by Capario, May 7, 2014)

Good information, sound advice, and a good goal to work toward this month.