Accepting Insurance Exchange Plans: What Physicians Must Consider

November 8, 2013
Marisa Torrieri

Doctors are pretty much split on whether they will accept the new healthcare insurance exchange plans. Should they?

Doctors are pretty much split on whether they will accept the new healthcare insurance exchange plans, according to a recent survey from the Medical Group Management Association (MGMA), based on more than 1,000 medical group members (representing more than 47,500 physicians). And many - 40 percent, in fact - still haven't settled on a decision.  

So if you're a physician or decision maker at your practice among the unsure, how do you figure out whether to participate in none, some, or all health insurance exchange plans?

One big consideration is whether you have an all-products clause in place: Twenty-seven percent of those surveyed who plan to participate cite these clauses as the chief reason for participation. 

"Some states have outlawed these all-products clauses in insurance contracts …but it's not the majority of states at this point," Anders Gilberg, senior vice president, government affairs, at MGMA, told Physicians Practice. "Some contracts require if you enter into a contract with to provide physician services for a health plan, then you have to accept all the products that they have, regardless if it’s one or a hundred." 

For hospital-owned or affiliated practices, sometimes the decision to accept exchange plans are outside of the control of the physicians themselves, which the survey also indicates, he adds. Financial considerations are multi-dimensional. Perhaps most pressing is the issue of how well the plans pay, and how incorporating new ones will affect your payer mix.

The top reason practices aren't planning to participate with ACA exchange products is concerns about administrative and regulatory burdens (according to 64 percent of the respondents who aren't planning to participate), closely followed by concerns about financial burdens from patient collections (62 percent). What it boils down to for many practices, is "whether or not you believe you need to participate in these products to remain competitive," said Gilberg.

"You want to look at the financial aspects of it, you want to look at it relative to your existing payer mix," said Gilberg. "Even if you have an existing relationship with a commercial plan, they may pay 30 percent less for the same services provided for an exchange patient. The rates appear to be, on average, closer to Medicare."  

While rates paid to physicians are "generally higher than Medicaid," they're not as high corporate employer insurance plans.

Another related consideration is collections, namely, whether accepting exchange plans with higher deductibles will make it harder to collect payments from patients.

"If a plan's deductible is $2,000, collections is going to be a significant administrative task for physician practices," says Gilberg. "Deductibles are huge for the lower-tier insurance products being sold on ACA exchanges."