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Physicians Risk Losing Payments Under Final Rule

News  |  By Credentialing Resource Center  
   July 05, 2017

Physicians run the risk of not getting paid by health plans for a patient who is ostensibly still on the health plan’s books.

This article was originally published on the Credentialing Resource Center, May 9, 2017.

A final rule issued by CMS could put physicians in jeopardy of not getting paid for services provided to patients covered under the Affordable Care Act (ACA).

The rule would require patients to pay past due premiums before re-enrolling in any of an exchange insurer’s products.

According to language in the final rule, it is meant to “improve the risk pool and promote stability in the individual insurance markets. We are taking several steps to increase the incentives for individuals to maintain enrollment in health coverage and decrease the incentives for individuals to enroll only after they discover they require medical services.”

The issue for physicians is that the ACA allows certain enrollees a three-month grace period to remain enrolled if they have not paid their premium, yet plans stop payments on claims after one month.

Physicians can be rendered unable to collect from the insurer for two months of claims if the debt is never cleared. Physicians run the risk of not getting paid by health plans for a patient who is ostensibly still on the health plan’s books.

The grace-period provision, which is given to enrollees receiving advance premium tax credits, applied to an estimated 9.4 million enrollees in 2016, according to the Kaiser Family Foundation.

“We agree steps must be taken promptly to stabilize the individual insurance market,” said AMA President Andrew W. Gurman, MD, but regulations “still need to address the resulting inequity of the ACA’s grace period, which allows issuers to collect unpaid premiums for months in which health care services were provided but not actually covered by insurance.”

Source: AMA

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