More Insights into the Health Insurance Exchange Plans and Their Tricks


Each day we learn more about how payers are processing claims. Here's what your medical practice needs to know.

A few weeks ago, I wrote about problems with the plans offered through the health insurance exchanges. The more we see how claims are processing, the more confused the entire system seems.

It reminds me of my high school computer programming class where I had to use “If/Then” statements:

• IF you have a contract with Blue Cross THEN you should be able to accept Blue Cross patients.
• IF this is a plan falling under the ACA, THEN that above statement is not necessarily true.
• IF the Insurance Exchanges get enough complaints from their new enrollees THEN they might consider adding you to their network honoring your current rates (and they lose money).
• IF they put you as in-network THEN you should be informed (but are not).

One of the big problems is that many physicians, labs, and private practices are not in these narrow networks found in the plans. This has resulted in the patient paying their monthly premiums, going to their doctors and receiving a large bill since it was processed out of network.

I actually have an employee who was looking for an exchange plan for her husband. A broker called her and pitched a Blue Shield plan (which we have been struggling so much with). He said, “I have not heard of any problems with Blue Shield.” She opted out of that plan since she is well aware of the problems patients are having due to the narrow networks.

One of our patients has switched plans three times in two months trying to find one where we are in-network with Blue Shield. He keeps striking out.

Brokers are making a commission in these plan “sales” and patients are paying the price.

A new plan emerged this past week: an EPO. We've had EPO's in the past. Patients with EPO plans have very few out-of-network benefits except emergency and catastrophic. So, then we have to turn the patients into cash patients, and all of the money that they've spent to buy this plan means absolutely nothing.

They want to yell at us, understandably so, but this is our (and your) opportunity to take control. You know you are a professional who deserves to be paid for your services. This is when you train your staff to “sell your practice” to the patient. What sets you apart? What makes your practice worth the patient paying cash?

As more patients encounter out-of-network problems, your practice will need to educate them in what out of network and in network mean. These new exchanges and the brokers are not going to share this information with patients.

It's not your fault, it's not patients' fault. This is your chance to retain that referral and prove your worth.


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