be paying a bill to us or not, or making decisions on whether to see them on a particular day.” TMA’s Mr. Spangler also cautions that patients’ possession of a health insurance ID card does not necessarily translate to active coverage if they haven’t paid their premiums. It also remains unclear whether health plans’ decisions to extend pre- mium payment deadlines for patients seeking January cover- age could delay physician payments for services delivered in January and February, the association’s Director of Payment Advocacy Genevieve Davis adds. As practices get a grasp on the different types of new ex- change products sold on the exchange, physicians also report difficulties navigating the myriad benefit structures, referral procedures, and other requirements to get patients the care they need.
“It’s not one new plan, but dozens, and from our experience, none of them are clear. Health plans themselves have trouble answering questions without understanding the implications” on practices and on patient care, Dr. Chenven said. Inaccurate directories, for example, coupled with difficult
referral mechanisms, make it difficult to get care preauthorized and to timely treat patients, physicians say. And a majority of the health plans include high deductibles that patients don’t understand and can’t afford.
“It’s madness,” he said, adding that ARC is monitoring the impact of patients who fall into the 90-day grace period.
Health plans respond Health plans acknowledge the rough start and say they are
taking steps to smooth the ride and mitigate physicians’ risk. “Health reform is a major initiative, and it’s always been clear that time would be needed to make all the different piec- es come together successfully,” Dr. McCoy said. “We’re here to best serve our members and are working hard to make sure the enrollment process is as seamless as possible. Our goal is to do everything possible to empower providers with informa- tion that will minimize risk.”
The Blues and Aetna were among plans that agreed to give patients more time to pay their January premiums to accom- modate the enrollment problems in the
healthcare.gov debut. Both declined to release specific enrollment numbers or pre- miums paid but said they are seeing a steady volume of enroll- ments and payments coming in and are educating patients about their coverage and payment obligations. Dr. McCoy says the Blues received the vast majority of pre- mium payments for Jan. 1 coverage. He clarifies, however, that although BCBSTX extended its payment deadlines, members wouldn’t be eligible for services and their claims wouldn’t be processed until they paid their first month’s premium. The influx of marketplace enrollments also means not all
new members with coverage beginning Jan. 1 received their ID cards on time, he says. Blues cards will display “BAV” for patients enrolled in the Blue Advantage HMO product it offers in the marketplace, but nothing will differentiate between the PPO plans it sells on and off the exchange. Aetna insurance cards will say “QHP” to indicate patients are in an exchange plan; Humana cards will say “HMOx.” While members await their ID cards, Dr. McCoy says BCB- STX is notifying physicians and other health professionals of temporary patient eligibility verification measures. If patients have their member ID number and group number from anoth- er source, such as a welcome letter or phone confirmation, for example, the Blues can verify eligibility and benefits. To verify patient eligibility, physicians can use the following when they call: patient name, subscriber name, patient mailing address, last four digits of the patient’s Social Security number, and effective date of coverage. Aetna says it sent similar welcome letters to its members.
Physicians calling the Blues will see an improvement in call wait times, and doctors can use the carrier’s electronic eligi- bility verification systems, both of which are “continually up- dated” and “will report information real-time,” Dr. McCoy said. Aetna officials say its eligibility, preauthorization, and re-
mARKETPLACE Q&A
“ACA Exchange Plans: Questions and Answers for Physicians” at www
.texmed.org/ExchangeQA.
24 TEXAS MEDICINE April 2014
Confused about whether your current contracts include you in market- place plans? Unsure about which plans are participating in the exchange and how to identify patients with this coverage? TMA answers your marketplace questions in detail. Go online to TMA’s
ferral processes are the same for exchange plans as for other commercial plans. “The networks for exchange plans are typically smaller than our standard networks, so it’s important to confirm [that a] provider is in the exchange network before referring,” representatives said in a statement. To help avoid nonpayment, the Blues and Aetna also encourage physicians to proactively check pa- tients’ eligibility and benefits before treatment.
“Obtaining eligibility and benefits prior to each visit is a good practice to mitigate risk, even if several visits have already been authorized,” Dr. McCoy said.
As for the 90-day grace period, “we recognize that this may require
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