Centers for Medicare and Medicaid | The Health Law Firm Blog

Grace Period Included in the Affordable Care Act Could Pose Financial Risk to Healthcare Professionals and Providers

By Michael L. Smith, R.R.T., J.D., Board Certified by The Florida Bar in Health Law, and George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

A little known rule published by CMS to implement the Affordable Care Act (ACA) could pose a significant financial risk for doctors, hospitals and other healthcare providers. The rule requires health plans participating in the exchanges to provide individuals purchasing insurance through the exchanges a grace period before terminating the coverage for non payment of the premiums. Doctors and other healthcare providers will continue to provide care during the grace period, but the insurance plan will not be required to pay the claims incurred during most of the grace period. The result could be that physicians and other healthcare providers would provide a significant amount of uncompensated care.

Details of the Rule.

The CMS rule provides individuals that purchased subsidized coverage through the exchanges a 90-day grace period before their coverage is cancelled for non payment. The insurance plan is required to pay any claims incurred during the first 30 days of the grace period, but the insurance plan is not required to pay the claims incurred during the last 60 days of the grace period if the individual’s coverage is terminated. The insurance plan is allowed to place all the claims during the last 60 days of the grace period in a pending status. The rule requires the insurance plan to notify the healthcare providers when an insured individual is in the last 60 days of the grace period.

Risk Falls on Healthcare Professionals and Providers.

The rule imposes a significant risk for uncompensated care on the healthcare providers. The rule does require insurers to tell healthcare providers when patients are behind on their premium payments, but he rule does not specify how the health plan will provide that notice to the providers. The only notice some providers receive will probably be the pending status placed on the unpaid claims by the insurance plan.

Many doctors and hospitals are reluctant to participate in insurance plans offered on the exchanges due to the increased financial risk associated with the CMS rule. The result could be that individuals enrolling in insurance plans through the exchanges may find it difficult to find a healthcare provider willing to accept them as patients. CMS has been asked to modify the rule so that insurers are required to pay claims during the entire 90-day grace period.

How Grace Period Can be Manipulated to Benefit Patients.

The CMS rule may also result in individuals manipulating the system. Some individuals may intentionally pay premiums for only part of the year and become serial abusers of the 90 day grace period. Another unintended consequence of the ACA is that individuals that choose not to pay their premiums and have their coverage terminated can reenter the exchange and enroll in a plan regardless of their pre-existing conditions so there is little incentive for some individuals to maintain their coverage.

Contact Health Law Attorneys Experienced in the Representation of Health Professionals and Providers.

The attorneys of The Health Law Firm provide legal representation to physicians, nurses, nurse practitioners, CRNAs, pain management doctors, dentists, pharmacists, psychologists and other health providers in insurance company or other third party payor reimbursements.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Comments?

Were you aware of the 90-day grace period? As a healthcare professional or provider, are you worried you don’t have adequate financial protection? Please leave any thoughtful comments below.

Sources:

Fiegl, Charles. “Medical Groups Fear ACA Grace Period Will Lead to Unpaid Claims.” American Medical News. (September 2, 2013). From: http://www.amednews.com/article/20130902/government/130909984/4/

Block, Jonathan. “Providers Protest Rule Putting Them at Financial Risk if Patients Don’t Pay Premiums.” Modern Healthcare. (August 13, 2013). From: http://www.modernhealthcare.com/article/20130813/NEWS/308139968

Adams, Samuel. “Hospitals May Absorb Risk of Insurers’ Debtor Patients.” Bloogberg. (August 17, 2013). From: http://www.bloomberg.com/news/2013-08-16/hospitals-may-pay-for-insurers-debtor-patients-under-obamacare.html

45 C.F.R. Section 156.270

About the Authors: Michael L. Smith, R.R.T., J.D., is Board Certified by The Florida Bar in Health Law. He is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

By The Health Law Firm|2024-03-14T10:00:53-04:00June 1, 2018|Categories: In the News, The Health Law Firm Blog|Tags: 90 day grace period, ACA, ACA grace period risks for physicians, Affordable Care Act, Centers for Medicare and Medicaid, CMS, defense attorney, defense lawyer, enrollees, grace period, grace period risks for providers, health insurance company, health insurance programs, health insurers, health law firm, health plan, healthcare reform law, hospitals, insurance exchange, Obamacare, practice administrators, premium payment delinquency, the health law firm, unpaid health insurance premiums, who pays claims during grace period, withhold payments on claims|Comments Off

Doctors’ Medicare Payment Data to be Released Spring 2014

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

For years, the Centers for Medicare and Medicaid Services (CMS) has kept private its records on Medicare claims payments made to individual physicians. However, beginning March 18, 2014, the government may disclose the payment data on a case-by-case basis. According to CMS, this directive is a push by the Obama Administration to crack down on doctors who are making a habit out of repeatedly overcharging Medicare. On January 15, 2014, CMS stated that recalcitrant providers could face civil fines and exclusion from Medicare and other federal health care programs. According to CMS, a recalcitrant provider is defined as one who is abusing the program and not changing inappropriate behavior even after extensive education to address these behaviors.

Data Made Public to Fight Healthcare Fraud.

According to The New York Times, federal officials estimate that 10 percent (10%) of payments in the fee-for-service Medical program are improper. Supporters of releasing the data say it could help identify patterns of waste and fraud. The Medicare payment data, combined with data from other sources, could be enormously useful to consumers, researchers and whistleblowers analyzing patterns of health spending.

Physician groups express caution in Medicare releasing individual payment information, saying it could lead to public misunderstanding and unintended consequences, according to The New York Times.

Click here to read the entire article from The New York Times.

Data Prohibited From Being Release for Past Thirty Years.

In 1979, a federal district judge in Jacksonville, Florida, issued an injunction that prohibited Medicare officials from releasing what Medicare pays individual doctors. The ruling, in a lawsuit filed by doctors, said such disclosure would violate the Privacy Act and constitute a clearly unwarranted invasion of personal privacy. In May 2013, the judge lifted the injunction.

According to a MedPage Today article, the decision does not require the wholesale release of Medicare payment data but allows Medicare officials and courts to consider the merits of each request.

To read the entire article from MedPage Today, click here.

Healthcare Providers Should Prepare for Possible Public Scrutiny.

Although it remains to be seen how CMS will implement its new policy, health care providers should be prepared for the possibility that their coding, billing and reimbursement patterns will become the subject of public scrutiny, particularly those providers in specialized areas including internal medicine, radiation oncology and ophthalmology.

Contact Health Law Attorneys Experienced with Healthcare Fraud Cases.

Attorneys with The Health Law Firm represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program. We also handle Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S.

Our attorneys also represent health care professionals and health facilities in qui tam or whistleblower cases both in defending such claims and in bringing such claims. We have developed relationships with recognized experts in health care accounting, health care financing, utilization review, medical review, filling, coding, and other services that assist us in such matters. We have represented doctors, nurses and others as relators in bringing qui tam or whistleblower cases, as well.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Comments?

What do you think about the decision to release payment data for physicians? How will this effect health care providers? Please leave any thoughtful comments below.

Sources:

Pear, Robert. “Doctors Abusing Medicare Face Fines and Expulsion.” The New York Times. (January 25, 2014). From: http://nyti.ms/1cpIaOg

Pittman, David. “Medicare to Release Doc Pay Data This Spring.” MedPage Today. (January 14, 2014). From: http://bit.ly/1ndaCHu

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

By The Health Law Firm|2024-03-14T10:00:54-04:00June 1, 2018|Categories: Health Care Industry, Medicare, The Health Law Firm Blog|Tags: Centers for Medicare and Medicaid, CMS, defense attorney, defense lawyer, doctor attorney, doctor lawyer, doctor payment information, doctors, exclusion from Medicare, expelled from Medicare, health law firm, improper payments, internal medicine, medically necessary claims, medically unnecessary claims, medicare, Medicare abuse, Medicare doctor services, Medicare fraud, Medicare payment data, Medicare payments, Medicare physician services, ophthalmology, overcharge Medicare, physician attorney, physician lawyer, physician payment information, physicians, radiation oncology, Recalcitrant providers, the health law firm|Comments Off

Verifying Patients’ Affordable Care Act Exchange Insurance is Putting Doctors’ Office Employees Through the Ringer

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

The ultimate goal of the Affordable Care Act (ACA) is to provide millions of previously uninsured Americans with access to health care. Open enrollment does not end until March 31, 2014; however, practices are already seeing an influx of patients who have bought insurance through the exchanges. With that, some offices are reporting a new challenge being presented in doctors’ offices.

In a National Public Radio (NPR) article, some doctors’ office employees report having to call insurance companies to verify that each exchange patient is paid up. These calls are reportedly taking up to an hour or more, which costs the practice both time and resources.

Click here to read the entire NPR article.

Doctors’ Offices Used to Check Insurance Online.

In the past, practices were able to verify patients’ insurance quickly through online verification systems. However, for exchange patients, some doctors’ offices are choosing to call insurance companies to make sure the patient has paid the premium. It if is not paid, the insurance company can refuse to pay the doctor for the visit, or recoup payments already made.

Financial Risk Part of the 90-Day Grace Period Included in the ACA.

Individuals that purchased subsidized coverage through the exchanges are granted a 90-day grace period before their coverage is cancelled for nonpayment. The insurance plan is required to pay any claims incurred during the first 30 days of the grace period. However, for the next 60 days, nothing is guaranteed. If a patient visits the doctor, the insurer can “pend” the claim and wait to pay until the patient pays the premium. At the end of the 90 days, the insurer can cancel the coverage and refuse to pay the pended claims or recoup payments already made. To read a previous blog on this topic, click here.

Risk Falls on Health Care Professionals and Providers.

The rule imposes a significant risk for uncompensated care on health care providers. The rule does require insurers to tell health care providers when patients are behind on their premium payments, but the rule does not specify how the health plan will provide that notice to the providers. This is why some practices are opting to get in front of the insurance companies by calling and verifying everything is in order before proceeding with the visit. However since the calls are taking so long, this means longer hours, more overtime and higher overhead expenses.

The Office Has Options.

If the premium is not paid, the office is at risk to not receive reimbursements. Instead of taking that risk, the office can provide patients with other options. The patient could reschedule the appointment for a later date. Or the patient could pay the office in cash and then apply to the insurer for reimbursements. Either way, the practice will receive its proper payment.

Contact Health Law Attorneys Experienced in the Representation of Health Professionals and Providers.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Comments?

Has your practice been calling insurance companies to verify patients have paid their premiums? As a health care professional or provider, are you worried you don’t have adequate financial protection? Please leave any thoughtful comments below.

Source:

Gold, Jenny. “Doctors’ Offices Get Put On Hold Trying to Find Out Who’s Insured.” National Public Radio. (February 25, 2014). From: http://www.npr.org/blogs/health/2014/02/25/282115303/doctors-offices-get-put-on-hold-trying-to-find-out-whos-insured

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

By The Health Law Firm|2024-03-14T10:00:55-04:00June 1, 2018|Categories: In the Know, The Health Law Firm Blog|Tags: 90 day grace period, ACA, ACA grace period risks for physicians, Affordable Care Act, Centers for Medicare and Medicaid, CMS, defense attorney, defense lawyer, enrollees, grace period, grace period risks for providers, health insurance company, health insurance programs, health insurers, health law firm, health plan, healthcare reform law, hospitals, insurance exchange, Obamacare, practice administrators, premium payment delinquency, the health law firm, unpaid health insurance premiums, who pays claims during grace period, withhold payments on claims|Comments Off