Thinking Ahead

The population of patients insured with marketplace health plans is growing — and with it comes a new set of challenges for radiologists.


February 2015

Under the Affordable Care Act, over 7.1 million individuals have successfully enrolled in and paid for plans under the health care marketplace.

Yet the Congressional Budget Office has predicted that by 2017, that number will rise to over 25 million and will continue to grow exponentially over the years.1,2 That's a critical piece of the patient population, and with that population comes a new set of challenges for radiologists and their practices, according to a recent article in the JACR®, "Here Come the Exchange Patients."3 Among those challenges is dealing with the grace period that these patients are given when they fail to pay their premium, notes article author Ezequiel Silva III, MD, vice chair of the Commission on Economics.

Understanding the Grace Period

Once patients fail to pay their first premium, they enter a 90-day grace period in which they are still covered by the insurance. However, to continue coverage beyond that period, patients must make up the back payments for the grace period and stay current with their premiums. Following the grace period, if a patient is still delinquent, he or she will be terminated from the insurance. This has several implications for the physician, says Silva. During the first 30 days of the grace period, patients maintain their coverage and little changes from a reimbursement perspective. However, during the second 30 days, the insurer is not responsible for paying claims — unless the patient pays the premium before the grace period ends.

How these later claims are processed depends on the insurance carrier, says Silva. Some insurers will hold the claims for the duration of the grace period. Others may grant reimbursement to physicians but then ask to be repaid by the physician should the patient continue to default on the premium. Obviously, neither of these are optimal situations; both put practices at risk for losing money.

Gathering Information

So what can you do? First, determine how you will be notified that your patients are within the grace period, says Silva. CMS requires that insurance companies notify physicians that their patient has lapsed on their payment and has entered the 90-day grace period, and that claims during this period could be denied. How insurance companies notify physicians, however, varies from provider to provider. Exactly when they must notify you is also not regulated, as long as it is sometime within the grace period.

Silva suggests that practices be proactive about obtaining this information by inquiring about your patients during the preauthorization process that often happens before an imaging procedure. This gives you the ability to make decisions about patients' care before they enter your office.

Taking Action

Next, what do you do when you encounter a patient who is within the grace period? First of all, it's important to note the things you cannot do. You cannot pay the patient's premium to enable your own payment, says Silva. Both the federal government and the AMA have released statements that cite those payments as inappropriate and unethical. But you should not completely deny care to grace-period patients either, adds Silva. If you are contracted with that insurer, refusing to provide care or providing incomplete care could be considered a breach of contract. Further, if you have established a doctor-

patient relationship, Silva notes that, as a physician, you are responsible for the patient's continuity of care.

What you can do is counsel your patient, says Silva. Sit down with your patient and find out the circumstances that have led to the patient's inability to pay his premiums. "A patient may tell you, 'I lost my job,' or 'I had a divorce' — these status changes could make them eligible for a different subsidy or marketplace plan that makes health care more affordable for them. And it is completely appropriate for an outpatient center or office to engage with a patient in that kind of discussion," Silva adds.

This is only one set of issues that patients under the marketplace can bring. "As the insurance plans in the marketplace shift and grow, we have a whole new population with a whole new set of challenges coming at us, and we don't have a good gauge of what's going to happen," says Silva. "We need to prepare for the issues we can predict while we can."

By Meghan Edwards, copywriter for the ACR Bulletin

1.US Department of Health and Human Services. Health Insurance Marketplace: Summary Enrollment Report for the Initial Open Enrollment Period. Published May 2014. Accessed January 5, 2015.
2.Congressional Budget Office. Updated estimates of the insurance coverage provisions of the Affordable Care Act. Published Feb. 2014. Accessed Sept. 12, 2014.
3.Silva E. Here come the exchange patients. JACR 2014;11(9):846. Accessed Sept. 2, 2014. Accessed Sept. 2, 2014.

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