Decision Day for Health Insurance Exchanges: 3 Questions

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Today is the drop-dead deadline  for the nation’s governors to declare whether or not they will participate in the state health insurance exchange program or not.

For the most part reporting about the exchanges has focused on its impact to state governments, consumers, and insurers. If you follow the news, one could infer that providers will be unaffected, other than more of their patients will be covered by insurance beginning Jan. 1, 2014.

After poring over countless documents and regulations from the US Department of Health and Human Services and other agencies, here are three questions we believe that revenue cycle professionals will want answered:

1. What’s to prevent insurers affiliated with exchanges from becoming another Medicaid? A key facet to the exchanges is that they promote competition among carriers in order to keep prices down. But does that mean that carriers, with the implicit approbation of state and federal governments who want to keep rates low, will employ that influence to further squeeze providers on pricing?

2. Who has to tell the patient “no”?  In Massachusetts, where an exchange is already in place, it has fallen to providers to explain insurance to patients. “Providers, who do not design insurance products, must not be put in the position of trying to explain these insurance products for the first time to consumers at the time of service,” the Massachusetts Hospital Association recently noted. As part of the Patient Protection and Affordable Care Act, healthcare providers will be measured in part based on patient satisfaction. Who is measuring the satisfaction of consumers with their insurance purchased through exchanges? Or will that, like other insurer issues, be transferred to the provider?

3. Will state exchanges mean a provider tax? Concern was raised during consideration of the federal regulations on exchanges that states would be able to implement a tax on providers to pay for the exchanges. The feds are leaving that up to the states. “Exchange flexibility in funding ongoing operations is critical, as we believe that the ability to pursue specific funding strategies may vary by State,” according to HHS response.

The exchanges need to be up and running by open enrollment on Oct. 1, 2013, for insurance to begin on Jan. 1, 2014.

States that intend to establish a partnership exchange must inform CMS by February 15, 2013. States that decide later to establish their own exchanges have until December 31, 2014 to apply for establishment grants.

On Monday the Department of Health and Human Services announced conditional approval for state exchanges in Colorado, Connecticut, Oregon, Washington, Maryland, and Massachusetts. Massachusetts, as mentioned above, already has its own insurance exchange.

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Posted in Denials Management, Medical Receivables, Patient Experience, Patient Financial Services .

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