SAN FRANCISCO -- Physicians could face dramatic financial challenges for treating patients who receive health coverage through the Affordable Care Act's (ACA) exchanges starting next year.
Insurance companies will not process claims on patients who haven't paid their premiums in 3 months, leaving doctors on the hook to recoup payment directly from the patients.
The ACA provides a 3-month grace period to individuals who haven't paid their premiums, and the provision could prove problematic for physicians, said Elizabeth McNeil, vice president of federal government relations at the California Medical Association (CMA) in Sacramento.
Plans will hold off on processing claims on customers who haven't paid after 2 months. After 3 months, it will deny all claims "and you will have to seek payment from the patient," McNeil said Friday at the American College of Physicians annual meeting. Patients will be free to sign up for another plan in the exchange and start seeing another provider.
"Why would a doctor sign up [to treat these patients] if they're going to be completely at risk and have to collect from the patient for the care?" she told 51˶. "This is a really bad provision in the bill, and we've got to get it fixed."
Under traditional insurance, the plan is still liable for paying doctors even if the patient or employer hasn't paid their premiums, McNeil said, but patients who will be covered under the ACA exchange may not be accustomed to the standard insurance payment set-up.
"This is a group of patients that aren't used to making insurance payments and making those monthly premium payments," she said. "That's a lot to keep up on. This is a lower-income, less-educated, busy [group of] people."
The expected annual, out-of-pocket cost for an individual is estimated to be around $6,400 and $12,800 for a family, which is not a small expense, McNeil said.
Provider organizations like the CMA have written comments to the Department of Health and Human Services requesting greater protections for physicians who treat these patients, and asking for more communication between insurance companies and providers about patients who haven't paid premiums.
"Ultimately, I think we may have to have physician organizations get together at the federal level to change this," McNeil said.
Another potential area where doctors could be shortchanged by treating patients in the exchange is with reimbursement rates, which will be different from those with employer-sponsored coverage.
"Physicians have been very mixed about that," McNeil said. "We have a lot of physicians who say it might be better if we have some sort of public rate-setting process. On the other hand, there are other physicians who say 'No, it's better we try to negotiate with the health plan.'"
It will be several months before doctors know what those rates will be. Like with the premium rates under plans sold under the exchange, McNeil said insurance companies are still setting the prices they will pay providers and won't finalize them till late summer or early fall.
Also, only the big provider groups are negotiating with plans on their payments. Small groups will only get a "take it or leave it" contract.
The unanswered questions could mean fewer doctors will sign up to accept patients receiving coverage through the exchanges, she said, leading to a provider shortage.
Physicians should also be aware that many of the patients receiving coverage through the exchange may not have had a doctor for some time, which could mean more complex cases, McNeil pointed out.