Doc groups call for real-time payment data on health exchanges

Physicians are at risk to lose payment for care they provide to patients insured under new health exchanges during the latter two months of a three-month nonpayment grace period allowed by the Centers for Medicare & Medicaid Services. In response, physician groups have deplored CMS to provide them with real-time data about patients' payment/delinquency status as part of the eligibility-check process, American Medical News reported.

As written, CMS rules require health plans on exchanges to notify all affected providers "as soon as practicable" once a beneficiary falls behind on payments and enters the grace period. Payers are responsible to cover claims incurred during the first 30 days of nonpayment, but are instructed to designate claims pending when submitted during the final two months before coverage is cancelled. Providers will then have to collect directly from patients after the fact, a predicament that physician groups consider unacceptable.

"Physicians, hospitals and other health care providers cannot reasonably be expected to know or predict if an enrollee's premiums are paid or will be paid before the end of the grace period," officials from the Missouri State Medical Association and the Missouri Hospital Association stated in an Aug. 12 letter to CMS. "And they cannot reasonably be expected to bear the concomitant burden of uncertainty and a potentially significant financial loss."

The Medical Group Management Association expressed similar concerns in a July 3 letter to CMS, in which MGMA-ACMPE President and CEO Susan Turney, M.D., wrote, "Permitting this latitude is unacceptable, especially considering that the insurers have ready access to the information that an enrollee has not paid his or her premium." 

To learn more:
- read the article from American Medical News