Will Doctors be Reimbursed Less by Exchange Plans?

Reimbursement rates for contracts obtained through the ACA exchanges have not yet been determined by almost all payers. The insurance companies have not set their reimbursement rates because they don’t know how many people they will have to cover from the exchange. Once they set the rates (likely in January), we believe that they will have to get the providers to agree to the reduced (if so) reimbursement, like Blue Cross did earlier in the year. Hospitals have negotiated contracts with payers already, and generally the reimbursement is the same as their commercial contracts, or slightly lower. Incidentally, more than 85% of Americans already have health insurance. The population in the Denver/Aurora/Boulder/Co Springs metro area is probably even more insured. It is unlikely that there will be enough local participation in the exchange plans that it will ever have a financial consequence to our clients.

In addition, while only one payer that we are aware of sent out letters inviting practices to participate in their exchange plan, it has not been determined if practices will be required to see patients who obtained their plan through an exchange. This is related to the “all products” clause that some payers have, but no one has had the opportunity to test these clauses under this circumstance. However, without signing a new contract, we don’t believe that a payer can force you to accept a lower reimbursement than you are currently contracted for certain patients. If reimbursements were somehow allowed to be lower than contracted rates, you could opt out of new patients for that payer, but theoretically not specifically related to one plan (such as the exchange plan.)

There is an issue about the risk of being reimbursed by the kind of patient that gets their coverage through the exchange. There is a clause in the ACA that allows payers to retroactively terminate a patient if they do not pay their premiums in the first three months for this reason. In those cases, the practice would have to try to collect any open claims from the patient, who may be more likely to default. This clause is being fought by several medical associations. As we all know, this Act was passed before anyone truly knew how it would work, so there is a lot of legal activity now that would have normally happened before the Act was passed.

Not all payers participated in the group exchange this year. For instance, United Health Care did not offer a plan on the exchange. They stated that if they do participate, they would likely reimburse at the contracted commercial rates. In addition, they only participated in the individual exchange in areas south of Pueblo and other rural areas.

We will obviously keep tabs on this, but at this time, we are not aware of any plan to reimburse at rates lower than your contracted rates by any payers.

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