Healthcare Payment System Still to be Built

Here is an article by Brian M Kalish that appeared in a newsletter I get. The article is dated January 18, 2014.

The back-end payment system of Healthcare.gov is still being built, a senior Centers for Medicare and Medicaid Services official said Thursday (January 16) in testimony on Capitol Hill.
 
“The automated process for payments is still being built, but we have a process in place that is working,” said Gary Cohen, director of the Center for Consumer Information and Insurance Oversight, in response to questioning by House Energy and Commerce Subcommittee on Oversight and Investigations Chairman Tim Murphy (R-Pa.). Cohen did not elaborate on the process in place.

Asked if there was a predicted finish date for the system, Cohen responded that he does not “have an answer on a predicted date.”

On Nov. 19, 2013, Henry Chao, the top IT official at CMS, said in testimony on Capitol Hill that more than 30% of the "back-end" infrastructure still remains to be built in the federally-run marketplace.

At the time, CMS Spokeswoman Julie Bataille said those tools included things needed in order to process payments to issuers, and they were not required until 2014. CMS added they were on track to complete these applications by mid-January.
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What does this mean to purchasers of individual & family health insurance - those who purchased inside the exchange?  For one, insurance companies may not receive your premiums (paid to the exchange) and the Federal tax credit money in time to guarantee coverage for January until sometime much later than normal.

Second, doctors and other providers unsure of being paid by the insurance company you chose in the exchange, will be skittish about "putting it on your tab" and crossing their fingers that payment will be made.

Third, your broker/agent that helped you enroll and kept you informed about the process won't get compensated until the back-end system is working.

This is all brand new territory for everyone - you the consumer, your doctors and other providers, the insurance companies and your broker.

Know Your Network!

We have become aware of information that you need to know.

Whether you have an individual & family health insurance plan or you are part of an employer sponsored group insurance plan, listen up!

2014 is the brave new world we read about in high school, especially regarding health insurance. My issue today is NETWORKS. Your plan has a network and it may be different than what you had last year. You need to know how to use your network to obtain benefits you are paying for and counting on. You also need to know how to avoid sticker shock when you don't play by the rules.

Gone are the days when you could say "My hip surgery is covered 100%."  Under old rules of insurance, it was true that you could have a hip surgery at a network hospital by a network surgeon and be covered to the full extent of your policy. But that was then. Shrinking networks make 2014 different.

It will not be uncommon for someone to get a hip surgery at a network hospital performed by a network surgeon and be covered for hospital and surgery expenses. However, it may happen that the anesthesiologist is out of network and the patient will be facing a huge bill. Most out of network providers are paid at a much lower percentage AND the out-of-network provider is allowed to balance bill. Here's another scenario -- the anesthesiologist is in network but he uses an anesthetic that is not in your formulary. For example, the anesthesiologist uses Propofol (not in the formulary) instead of Desflurane (in the formulary) and you get stuck with the cost of that drug. (My disclaimer - these drug names are strictly to make a point).

So what do you do?

Before you agree to a procedure - major/expensive test, outpatient surgery, inpatient surgery - or anything that is going to cost more than pocket change, ASK QUESTIONS! Call customer service (the 800# on the back of your ID card) and ask detailed questions about the procedure/surgery recommended such as…

1) Is this surgery for my leaking gizzard a covered expense?

2) Is this hospital or this ambulatory surgical center in network?

3) is this surgeon in network?

4) Is this anesthesiologist in network?

5) What about the anesthesia that will be used, is it covered? (You'll need to get the name of the Rx from the surgeon or the anesthesiologist)

6) Is the post-op therapy covered?

7) If I need durable medical equipment (knee scooter, wheelchair, oxygen tank, etc.) is it a covered expense?

8) If I need to stay in a rehabilitation wing of the hospital or at a remote facility, how is it covered?

9) If any of my treatment is performed at a facility or by providers out of network, what are my responsibilities?

I'm sure you get my drift. And keep a journal with names, dates and times that you made the calls and what you were told. If you later have to appeal a declination of benefits, accurate journal notes may make all the difference in whether you are successful in your claim or if you are denied benefits.

If you don't already have one, get a 3-ring binder for your Health History. Have tabs for Vital Statistics (weight, blood pressure, etc.), Medicines (and supplements you take), Office visits, Labs and Tests, Surgeries (inpatient and outpatient), Hospital Stays and other notes such as when and why you were sick and how you treated yourself even if you didn't see a doctor. Take the binder with you to doctor appointments. (I do this myself)