lationship. Thus, a professional relation- ship that was terminated because of a patient’s unwillingness to follow medical advice could be created once again. The contract also should be examined for any stated patient minimums, and the physician should ensure that his or her practice has the ability to handle the caseload.
Still other provisions in contracts
regulate when a physician may collect payment from patients. Some insurers prohibit collection of patient responsi- bility until the insurer has processed the claim and sent out explanations of ben- efits. Physicians should review contracts and the physician manuals to determine the collection parameters to which the practice has agreed to be bound. Close scrutiny of the physician’s obligations is a must.
Q: If I receive notice that patients are within the grace period, may I just pay their premiums so that they have coverage while I provide services? A: That may be a risky practice and can’t necessarily be recommended. The Cen- ters for Medicare & Medicaid Services (CMS) posted an addendum to its fre- quently asked questions regarding the Affordable Care Act on this very ques- tion. CMS states:
The Department of Health and Hu- man Services (HHS) has broad au- thority to regulate the Federal and State Marketplaces (e.g., section 1321(a) of the Affordable Care Act). It has been suggested that hospitals, other health care providers, and other commercial entities may be consider- ing supporting premium payments and cost sharing obligations with respect to qualified health plans purchased by patients in the Market- places. HHS has significant concerns with this practice because it could skew the insurance risk pool and create an unlevel field in the Market- places. HHS discourages this practice and encourages issuers to reject such third party payments. HHS intends to monitor this practice and to take ap- propriate action, if necessary.
10 TEXAS MEDICINE February 2014
So, the federal government is in- structing insurers to refuse these pay- ments and warning physicians and pro- viders that paying the patient responsi- bility could elicit regulatory scrutiny. TMA also has an ethics opinion on the topic. That opinion holds that pay- ing the premium is an ethical practice only if the physician does not directly or indirectly receive a benefit. It states:
Paying for Insurance Premiums It is ethical for a physician to pay a patient’s insurance premiums pro- vided the physician does not receive a direct or indirect benefit. Thus, a physician should not charge or bill the patient or his insurance company for the physician’s services to that pa- tient. Such payments should only be made in compliance with state and federal law and where true hardship exists.
Q: If I am contracted with an insurer, does that mean I am participating in that insurer’s Affordable Care Act ex- change plans? A: Not necessarily. Just because a physi- cian may have a contract with an insurer does not necessarily mean that physician is included in the network of plans that insurer offers. In Texas, 12 insurers are offering
plans on the federal insurance exchange, or marketplace. The federal insurance exchange is composed of state-regulat- ed insurance products offered by insur- ers. These are commercial insurance products, and your contract with insur- ers will dictate participation in insurers› networks. Typically, physicians agree to participate in insurer networks through a contract provision known as an “all products clause.” Here is a typical example of an “all
products clause”:
Medical practice agrees to participate in the plans and other health prod- ucts as described in this Agreement. Company reserves the right to intro- duce, modify, and designate medi- cal practice›s participation in plans and products during the term of the Agreement.
Note that the physician has agreed to participate in all plans as designated by the insurance company. Just as im- portant, note that the company has not agreed to designate the physician as par- ticipating in all plans.
Thus, depending on your contract, you may not be able to reliably answer patient questions about your partici- pation in federal insurance exchange networks without further research. A physician must ask the insurer whether he or she is in the plans offered on the exchange.
Another method of verification is to
go to the insurer websites and search for the physician through the carrier’s “provider finder” tools. Patients also can perform this search. Some insurers have created special exchange networks and invited only a limited number of physi- cians into those networks. Other insurers may tier or offer ex- clusive access based on their ratings sys- tems, essentially creating an exclusive “high performers” tier out of its normal network. There is no prohibition of these methods of designation or exclusion. Careful review of contract terms and fee schedules is a must in this new environment.
Q: Which insurance companies offer exchange products in Texas? A: The 12 insurers are:
• Blue Cross and Blue Shield of Texas, • FirstCare Health Plans, • Humana Health Plans of Texas, • Humana Insurance Company, • Aetna, • Cigna Health and Life Insurance Com- pany,
• Scott & White Health Plan, • Sendero Health Plans, • Ambetter from Superior Health Plan, • Community First, • Community Health Choice, and • Molina Health Plan.
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