Patient Payment Frustrations With Payers

April 6, 2015

Physicians are not the only ones who have difficulties with payers. Patients are being challenged with more restrictive coverage.

In the first year of healthcare exchanges, more than 60 percent of patients purchased a Silver plan with a $6,000 annual deductible, and another 20 percent chose a Bronze plan with a $10,000 annual deductible, says Tom Furr, chief executive officer at PatientPay, Inc., in a Physicians Practice blog, "Three Tips to Improve Your Billing Process" (bit.ly/improve-billing).

That amounts to a huge, upfront, patient responsibility for medical expenses; one that many patients don't understand.

Jane Siegel, an orthopedic hand surgeon based in Nashville, says it's not uncommon for patients who are enrolled in high-deductible plans to become upset when they find out how much they have to pay. "People are foregoing their carpal tunnel release, or their colonoscopy, or necessary procedures because they'll have to come up with $2,000 or $3,000 out of pocket," she says. Or if they do go ahead with the procedure, when the bill comes they say, "Well, I can't pay this." Siegel says it is a big problem for her practice, Tennessee Orthopedic Alliance. The practice typically works with disadvantaged patients, creating a payment plan and giving a discount to self-pay patients who live at or near the poverty line. But it's problematic when exchange patients also want a steep discount. "We can't do that because of negotiations with the insurance company; that would be insurance fraud," she says.

Another problem with the new health insurance exchange plans is the 60-day grace period. Patients are eligible for medical coverage once they sign up, but have 60 days to pay their first premium. If the patient receives care, doesn't pay the premium, and drops his insurance coverage within those 60 days, the physician is left on the hook for payment. Even if the practice confirms coverage prior to treatment, the patient may not make his first payment and lose coverage after treatment has occurred. The insurance company isn't required to pay for care in this instance, and essentially transfers financial liability to the physician.