“It’s madness.”
They rescheduled the patient for the next day when they had more time to spend investigating his situation. In the meantime, knowing the man needed a computed tomography scan, Dr. King initiated the preauthorization process, but the company could not find the patient in its system either. When staff called back the next day, it took more than
an hour to get through. Even then the insurance company could not immediately find the patient in its system. Another 15 minutes later, plan representatives confirmed the patient bought one of its bronze exchange plans but couldn’t tell Dr. King the patient’s deductible. He arranged for a hospital to take the patient on an emer- gent basis and convinced an oncologist to accept his referral even though the specialist at the time said he wasn’t participat- ing in any exchange plans. Like many physicians, the oncolo- gist chose to opt out over concerns patients can’t afford to pay the premiums and deductibles, which puts physicians at risk of not getting paid, especially for costly specialty care. Dr. King “had no choice” because his insurance contract automatically included him in one of its exchange plans. He says the widespread problems with the rollout of the
exchange — from government enrollment delays and errors to questionable health plan policies and networks — don’t merely disrupt physicians’ office operations. They affect patients’ ac- cess to care.
“Once patients walk in the door and we accept them, we are
responsible for their medical care, regardless of whether they can pay,” Dr. King said. But when it comes to the marketplace, doctors have a hard time fulfilling that duty because “it’s a mess. We can’t tell by looking at a card whether they are on the exchange, and if they are, how big their deductible is. So for everybody who walks in the door, we have to call to find out, but we can’t even get through. And a lot of these patients have never had insurance before, and they don’t understand.” While patients expect to be cared for, marketplace rules expect physicians to bear the financial risk, he adds. Dr. King eventually found out the patient’s deductible was so high, he likely could not afford to pay it, which means he also couldn’t afford to pay for care out of pocket. “We probably won’t get paid for this case. But this patient was better off having no insurance at all and seeking charity care,” he said. Moreover, if patients with subsidized marketplace coverage
don’t pay their premiums for 90 days, physicians run the risk of health plans’ clawing back any payments made during that timeframe. Dr. King expects more referrals like this one as newly in-
18 TEXAS MEDICINE April 2014
sured patients who went for years without care start visit- ing doctors’ offices. But if the confusion and burdensome rules persist, “physicians are the ones who will be left hanging, and that is a signifi- cant concern.”
Land of confusion Even as the federal government attempts to smooth out the
rocky launch of the marketplace that began Oct. 1, physician practices encounter new twists and turns they must navigate: The botched enrollment process on the faulty federal website and extended premium payment deadlines make it extremely difficult for practices to verify patient eligibility. Unreliable health plan directories and spotty participation fuel confusion about network access. Meanwhile, newly insured patients en- ter physicians’ offices with vague health plan identification that equates to questionable coverage. Further complicating matters is yet another federal policy — a so-called “smooth transition” rule — that encourages insur- ers to treat physicians as in-network even if plans don’t update their directories to reflect the fact that physicians either opted out or plans never included them in the first place. And physicians still have to grapple with a rule that puts their payments at risk if patients with subsidized marketplace coverage fail to make their premium payments for 90 days. (See “90-Day Notice,” opposite page.). The latest federal fig- ures show that 79 percent of the more than 200,000 Texans enrolled in marketplace plans were eligible for financial as- sistance. (See “Marketplace Q&A,” page 24.) TMA continues to advocate for legislative and regulatory
relief from rules like these that attempt to operate and fund the exchange at physicians’ expense. “This is a federal problem that requires a federal solution, so we have made our perspective known to federal agencies,” TMA Vice President for Medical Economics Lee Spangler said. He adds TMA is working with Texas exchange plans to help
streamline eligibility verification and notification processes so physicians can timely and appropriately care for this new population of patients. Meanwhile, TMA officials urge physicians to remain vigilant in their business practices surrounding the marketplace. Is- sues with health plan networks persist as physicians continue to report a lack of communication by insurers about whether their contracts automatically include doctors in marketplace products. (See “Untested Waters,” December 2013 Texas Medi- cine, pages 37–43, and “Marketplace Q&A,” page 24.) As TMA continues to field physicians’ inquiries about how to opt out of these plans, concerns mount about the adequacy of exchange plan networks and access to care. For their part, Centers for Medicare & Medicaid Services (CMS) officials say they are working daily to ensure the mar- ketplace runs smoothly. Between Oct. 1, 2013, and Feb. 1, 2014, 3.3 million people
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