Health Exchange Open Enrollment for 2015

November 15, 2014

As the health exchange open enrollment period begins, here are some tips for managing new health insurance plans better than your practice did in 2014.

Last February many practices experienced the full affect of new Affordable Care Act plans; in a very negative way. Few were prepared for the effects of out-of-network plans, narrowed network plans, and mirrored plans. There was little to no communication from the insurance companies. And patients were often sold plans where none of their physicians, labs, radiology groups, or rehabilitation centers was in-network, despite what they were told.

Insurance websites were not accurate: They often did not show the status of out-of-network practitioners. So, when patient claims started processing at 50 percent (out-of-network rates applied) everyone was sent scrambling. Patients were yelling at their physicians, and physicians were asking why their patients had purchased a plan that did not include them as in-network. Complete mayhem. Finger pointing, and absolute frustration ensued.

Once everyone calmed down, we realized insurance companies had not disclosed all pertinent information. So, the focus changed, patients felt empowered to call up their insurance plans and attempt to resolve these problems. Many were granted "continuation of care" authorizations, most just stopped going to the doctor. This has created the opposite effect of what the ACA originally had hoped to accomplish.

I'm bringing all of this up again, not to throw stones at the insurance companies, but to inform you that it is "open enrollment" for these plans again. The plans will go into effect on Jan. 1, 2015.

If your practice was affected by these new plans this past year, now is the time to think about a battle plan and how to implement it, before the new year begins. Here are some points you should add to your plan:

• While your staff is verifying the patient's insurance (oftentimes this happens before the patient comes in, and they do not have a copy of the insurance card yet) it's a good idea to ask, "Is this a (name your state) plan covered under an exchange?"

• Ask the insurance company if they show your practice as in-network or out-of-network.

• Create a document for the patient to sign that states: If the insurance coverage ends up being out-of-network (despite what the insurance company may have told your staff) the patient agrees to pay out-of-network rates.

• Provide the patient with the insurance company phone number at the first visit and ask them to call and verify their benefits as well. By teaming up with the patient at the beginning, it will let the patient know that you are working withthem and not against them. When problems happen, they are more apt to call the insurance company first, rather than call to yell at your staff.

• Monitor the alpha-prefixes and group numbers for any plans that do process out-of-network. By identifying these upfront at the time of verification, you can notify the patient right away and ask them to follow up with their insurance plan.

The bottom line is to be prepared as much as possible. Have a game plan ready to go and manage these plans with thoughtfulness instead of screaming chaos. It will best serve your practice and help you retain good relationships with your patients.