MDNews - Long Island

A S THE INDUSTRY PREPARES ITSELF FOR ANOTHER ROUND OF HE ALTHCARE REFORM, PROVIDERS SHOULD CAREFULLY MONITOR THE COVER AGE OF NE W AND E XISTING PATIENTS PRESENTING WITH INSUR ANCE POLICIES OBTAINED THROUGH STATE AND FEDER AL E XCHANGE PROGR AMS. LEGISL ATION INTRODUCED BY Republican lawma kers aimed at repea ling a nd/or replacing por tions of the ACA genera lly eliminates individua l and employer responsibility provisions ma ndati ng conti nuous covera ge retroactive to 2016. A s "appropriate cha nges" a re made, one ca n sa fely assume the instabi lit y of t he indiv idua l ma rketplace w i l l be of g reat concern to providers a nd for Qua lif ied Hea lth Pla n (Q HP) enrollees. One rea sonably predictable consequence of this instability could require providers to review their willingness to accept a n even g reater risk of rendering uncompensated care when treating Q HP enrollees receiving federa l subsidies at the end of 2017. Brief ly, as has been widely discussed, enrollees in Q HPs a re a fforded a 90-day "g race period" within which the Q HP enrol lee ha s 90 days to pay outsta nding premiums before bei n g ter m i nated f rom h is or her excha n ge pla n . W h i le excha nge payors a re obligated to process a nd pay cla ims for the f irst month a nd notif y providers of their enrollee's delinquency a f ter the f irst 30 days of non-pay ment, risk is pa ssed to prov iders in the rema inder of this g race period. Cla ims a re "pended" by ca rriers until such time as enrollees either satisf y outsta nding premiums or, a lternatively, a re terminated a f ter 90 days of non-pay ment . The member 's enrollment status prior to the end of his or her g race period, in ma ny insta nces, prevents collection from the patient until the member becomes forma lly terminated. Sta keholders have expressed concern that this 90-day grace period cou ld be abused, a s indiv idua ls cou ld be "covered" for 12 months while only paying nine months of premiums. Review of data published by CMS discounts these concerns, as failure to attain continuous coverage has been obser ved to be the result of cha nges in the member's enrollment status a nd ex terna l factors not inherently related to abuse of the g race period during the f ina l three months of the ca lenda r yea r. 1, 2 A s log ica l derivatives of proposed Republica n hea lthca re reform remove both economic and eligibility inducements for enrollees to rema in covered as pa r t of ACA excha nges, key constraints tempering concern for subsidized QHP enrollees abusing 90-day grace periods would also be eliminated. Marketplace instability and remova l of pena lties make the transfer of risk for days 31 to 90 of this grace period a rea listic concern for providers who wish to ma ximize cash flow and limit bad debts at the end of CY 2017. A ll sta should ta ke additiona l steps to ensure individua ls are eligible before and upon presentation and are not currently in any grace period, and to expeditiously communicate "pended" claims within and between a ll interested departments. Targeted questions and memorialization of all communications with exchange payors, reasonable and appropriate inquiries with Q HP enrollees in grace periods, and a review of individua l payors' grace period notification protocols may all help alleviate potentially negative outcomes for the patient and provider. Documentation of the above good fa ith effor ts will a llow in-house depa r tments or contracted vendors to verif y payors properly followed requirements imposed by federal regulations during grace periods and ensure any and a ll liabilities covered by the patient 's Q HP a re quick ly identif ied a nd recovered. Ross Steele, Esq., is an Associate Attorney at Miller & Milone, P.C. His practice focuses mainly on reviewing global trends and claim-specific issues within the framework of contractual agreements and regulatory provisions governing payors in claim adjudication, specifically assessing how developments in federal and state healthcare policy impact revenue cycle and payment models. He received his Juris Doctor from the Maurice A . Deane School of Law at Hofstra University, previously served as a senior fellow for The G itenstein Institute for Health Law and Policy, and is licensed to practice in the states of New York and New Jersey. ■ 1. h t t p : / / w w w . c b p p . o r g / r e s e a r c h / h e a l t h / mar ketpl ace- gr ace-per iods-wor king-as-intended 2. https://academyhealth.confex.com/academyhealth/2016arm/mediafile/ Presentation/Session4923/Keri%20Apostle.pdf BY ROSS STEELE, ESQ. Reopens Concerns Regarding QHP Subsidized Enrollee Grace Periods POTENTIAL REPEAL OF ACA MANDATES 1 8H E A LT H C A R E R E F O R M

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