Doc groups urge CMS to remedy grace-period risks

Physicians and other healthcare providers need immediate notification when patients insured under health exchanges enter the 90-grace period for nonpayment. More than 80 physician organizations--including the American Medical Association and Medical Group Management Association--voiced that request in a recent letter to Marilyn Tavenner, administrator of the Centers for Medicare & Medicaid Services.

In a change from proposed rules that held health insurance issuers responsible for unpaid claims incurred throughout the entire grace period, "CMS has unfairly shifted the burden and risk of potential loss for patient non-payment of premiums to physicians," the letter stated. "This financial burden will be untenable for many physicians."

As of now, issuers must pay claims incurred during the first month of the grace period only, and they're not obligated to inform providers of patients' nonpayment status until months two and three. "The timing and manner of such notice is left to the discretion of the issuers," the letter noted. "We believe these current notice requirements are inadequate and will lead to administrative confusion for physicians and practices."

The situation already caused major disruptions in office workflow, as practice employees reportedly spend hours on the phone with insurers attempting to verify insurance coverage and payment status.

"In particular, we urge CMS to require issuers to notify providers of a patient's grace period status as part of the insurance eligibility verification process," the letter continued. In addition, it requested that payment status become available via insurer's online portals. The physician groups also argued that insurance issuers should be financially responsible for claims incurred during the last 60 days of the grace period if the issuer provides inaccurate eligibility information.

To learn more:
- read the letter