Reviewing Payer Enrollment Agreements a Must for Medical Practices

December 24, 2013

Physicians are at odds waiting for new insurance plans offered through the healthcare exchanges. Here are concrete steps practices can take now to prepare.

The rollout of the new healthcare exchanges has been fraught with technical glitches and varying degrees of acceptance. But, the one fact that is certain is that come Jan. 1, 2014, there will be hundreds of new insurance plans across the country.

Information is sparse, and practices are unfortunately left hanging, unable to prepare for new patients with any number of new health insurance plans. Or are they? Healthcare attorney Eileen Elliott has decades of experience in healthcare and employment law. Elliott, who is a partner at Dunkiel Saunders, a Burlington, Vt.-based law firm, commiserates with physicians who don't know what to expect.

"A lot of physicians simply don't … necessarily know when they see a [new] patient, who he is covered by, what the plan is, what the reimbursement is going to be, and so, they are kind of operating blind, in a ways," said Elliott.

However, that doesn't need to be the case if physicians take the time to do a little market research beforehand. Elliott says "we need to get a little bit of experience" which will come from time and patience on the part of physicians.

Recently, Physicians Practice spoke with Elliott about the new insurance plans created through the healthcare exchanges and how physicians can prepare themselves and their practices for new insurance products.

Q: If a physician has an existing contract with a payer, would she be able to opt out of any new plans offered by that payer through the exchanges?

A: I think [physicians] would have the option to participate or not participate, and I think they would find out about that based on their contracts. I'm speaking in the abstract, but, in general, a contract or a provider enrollment agreement will include the terms that the provider is agreeing to accept, and what her arrangement is with that insurance company. If the insurance company isn't offering the plan anymore … then the provider enrollment agreement would be defunct.

Q: Some insurance companies have an "all products clause" built into their contracts, which essentially says, "If we choose to create a new product that's part of our plan, you are automatically enrolled, unless you opt out." Is this something physicians should be concerned about?

A: I would tell physicians that they really need to go in and read their provider enrollment agreements and see what sort of obligations the insurance companies have to notify them about changes. I know that is an additional kind of paperwork that must drive a lot of physicians crazy. But, if there is that kind of rollover, in contracts we call it an "evergreen clause" … you really need to read the provider enrollment agreement and see if the insurance company has any duty to notify. And, if they don't, I think there's probably a time you need to reach out to the insurance company and say, "What's going on?"

Q: Could you give me some best practices for physicians; things they can do now, before the new insurance plans start rolling out?

A: Review all of your provider agreements. I know time is short, but I think that needs to be done. I think one of the things that is really concerning physicians right now is when Jan. 2, 2014, rolls around, will people have insurance? A lot of physicians in general are supporting the increased access that the Affordable Care Act will provide, but with all the problems with enrollment through the exchanges, they are really concerned about what's going to happen in January. How do you know? How will people be able to pay for their insurance? So, best practices are going to be around confirming that the individual has Medicaid or has insurance.

Q: So, it sounds like you are recommending that physicians continue to do what they have always done: confirm coverage, enrollment benefits, copays, and deductibles prior to the patient visit?

A: Yes, especially in January, especially for new patients. I think there's a lot that can be done now. I think these last two weeks in December are kind of low [in patient visits], people don't go in the hospital as much, people defer care because they are doing other things for the holidays. And it may be a good time, as good as any, for billing departments to read those provider enrollment agreements and then try to get information from the insurance companies about what kind of changes they can expect in January.

To e-mail Elliott, click here.