ON AIR NOW

LISTEN NOW

Weather

cloudy-day
74°
Partly Cloudy
H 56° L 35°
  • cloudy-day
    74°
    Current Conditions
    Partly Cloudy. H 56° L 35°
  • cloudy-day
    54°
    Afternoon
    Partly Cloudy. H 56° L 35°
  • clear-night
    49°
    Evening
    Clear. H 56° L 35°
LISTEN
PAUSE
ERROR

Krmg news on demand

00:00 | 00:00

LISTEN
PAUSE
ERROR

Krmg traffic on demand

00:00 | 00:00

LISTEN
PAUSE
ERROR

Krmg weather on demand

00:00 | 00:00

New ACA insurance causes headaches in some doctors' offices

Sheila Lawless is the office manager at a small rheumatology practice in Wichita Falls, Texas, about two hours outside of Dallas. She makes sure everything in the office runs smoothly – scheduling patients, collecting payments, keeping the lights on. Recently she added another duty--incorporating the trickle of patients with insurance plans purchased on the new Affordable Care Act exchanges

Open enrollment doesn’t end until March 31, but people who have already bought Obamacare plans are beginning to use them. “We had a spattering in January—maybe once a week. But I think we’re averaging two to three a day now,” says Lawless. 

 That doesn’t sound like many new customers, but it’s presented a major challenge: verifying that these patients have insurance. Each exchange patient has required the practice to spend an hour or more on the phone with the insurance company. “We’ve been on hold for an hour, an hour and 20, an hour and 45, been disconnected, have to call back again and repeat the process,” she explains. Those sorts of hold times add up fast. 

>> Read more trending stories  

In the past, offices have been able to make sure patients are insured quickly, by using an online verification system. But for exchange patients, practices also have to call the insurer to make sure the patient has paid his premium. If he hasn’t, the insurance company can refuse to pay the doctor for the visit, or come back later and recoup a payment it made. 

That’s because of a provision of the law that gives exchange patients who neglect to pay their premium a “grace period” of up to 90 days. During the first 30 days, insurers have to pay any claims incurred by the patient. But for the next 60 days, nothing is guaranteed. If the patient visits the doctor, the insurer can “pend” the claim – that is, wait to pay the doctor until the patient pays his premium. At the end of the 90-day grace period, if the patient has not paid the premium, the insurer can cancel the coverage and refuse to pay the pended claims, or recoup the payments it’s already made.  And that puts the doctor’s office at risk. 

So Lawless is checking first with the insurer to make sure that everything is in order before proceeding with the visit. If the premium has not been paid, Lawless gives the patient the option of rescheduling the appointment or paying in cash and then applying to his insurer for the payment. 

“Most small practices run lean and mean – you’ve got one or two people to do this process plus do their other job duties that day as well, which is tend to the patients in front of them,” says Lawless. To manage the new workload, she’s had other staffers, including nurses, step in to answer the phone. And that means longer hours, more overtime, and higher overhead expenses. And then there’s the plain old annoyance factor. 

“You call in and you hit option prompts and you get to listen to no less than an hour of Blue Cross Blue Shield intro music. I could sing you the tune, that’s how often I’ve had to listen to it,” she says. “My staff said yesterday, it’s a sad shame within their prompts you can’t pick your music as well. If you’re going to have to wait that long, at least let us listen to what we want to listen to!” 

Blue Cross Blue Shield in Texas is the only insurer offering exchange plans in Wichita Falls. Dr. Dan McCoy, the company’s chief medical officer, says part of the problem was the health law’s compressed timeline. 

“Clearly at the end of December there were a significant number of members that enrolled and it’s taken some time to work through that volume in membership,” explains McCoy. “And we know this is a new day in the transformation of American health care. So it’s going to take a little bit of time to work through that.” 

Health Care Service Corp., which owns Blue Cross Blue Shield of Texas, has tried to address the situation by adding another 600 employees at its call center to handle the influx of calls and by extending business hours. McCoy has also been working directly with the Texas Medical Association to work out the kinks. 

Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association in Washington, D.C., a trade group for practice administrators, says the real problem is that signing up for coverage on the exchange isn’t as simple as the White House has made it sound. 

“What we’ve found is that messaging out of the [Obama] administration right now that’s aimed at the public, it tends to oversimplify the complexity of what it takes to get covered on the exchanges,” says Gilberg. “Just because you enrolled in coverage doesn’t mean your coverage is effective.” 

Even if patients pay their premium right away, it could be up to six weeks before their coverage actually starts. To have insurance start at the beginning of a month, the coverage generally must be purchased by the middle of the previous month. A plan purchased on Feb. 14 would be effective March 1. But a plan purchased on Feb. 16, for example, would not become effective until April 1. Go to the doctor before then, and your insurer doesn’t pay. 

“It’s not a surprise that given the subtle nuances and differences of what these exchange products are, that you’re in a gray area right now where there’s a little confusion on the patient side and the practice side. And I think that’s what we’re seeing a lot of right now,” says Gilberg. 

For a brand new program, that’s to be expected, he adds. And it doesn’t mean the exchange isn’t working. The real test will be what happens in April, when open enrollment ends and everyone who has purchased a plan offered through the health law’s online exchanges plan is clearly covered. 

In the meantime, Lawless offers this advice to patients who have bought plans on the exchange: “If you pay your premium prior to [visiting the doctor], print that out and bring it with you because that will certainly save all a lot of grief.”

Read More
VIEW COMMENTS

There are no comments yet. Be the first to post your thoughts. or Register.

  • We have updated information regarding a Tulsa homicide Friday night near East 36th Street and South 137th East Avenue. Police tell us Phazon Scott surrendered to investigators around 9:45 p.m. He will be booked into the Tulsa County Jail for first-degree murder. The unidentified 40-year-old victim was found fatally shot inside a house around 6:37 p.m. “The victim wanted to talk to the grandmother about a situation at the house involving his children,” police said.   “Scott arrived and entered the house and he and the victim had an argument. During the course of the argument Scott pulled a handgun from his waistband and shot the victim.” Scott then left the scene with the gun.  He later returned to the home and surrendered.   
  • KRMG has learned Gov. Mary Fallin vetoed 'most' of the revised budget bill passed by lawmakers this week. In a statement released by her office, Fallin says, “House Bill 1019X does not provide a long-term solution to the re-occurring budget deficits, and within three months we will come back facing an estimated $600 million shortfall.' Fallin vetoed 165 of 170 sections in the bill.  She did leave intact provisions for the Department of Mental Health, the Department of Human Services, Oklahoma Health Care Authority, the Department of Health, and the Department of Mental Health and Substance Abuse Services. Statement from the Tulsa Regional Chamber: “We at the Tulsa Regional Chamber strongly applaud Governor Fallin’s decision to veto much of the revised budget sent to her by the legislature Friday. Her courage in demanding real solutions to our budget crisis – not merely kicking the can down the road – is admirable and necessary. Oklahomans expect elected officials to be responsible stewards of public funds and navigate a sound budget for the state. We support Governor Fallin’s leadership tonight in demanding a higher standard for all Oklahomans.”
  • If you have a kite, today will be perfect to take it out to the park. National Weather Service Meteorologist Bart Haake says it's going to be windy in the Tulsa area. “It looks like we’ll see partly cloudy skies,” Haake said.  “We’ll see breezy northerly winds, probably in the 20 to 30 mile an hour range.” The sun is also expected to make an appearance.  NWS reports the high will only reach around 57 degrees.   There is a wind advisory in effect from 6 a.m. until 5 p.m.   It’s going to get chilly Saturday night.  Temperatures are expected to drop to around 35 degrees.  
  • An Ohio pastor, arrested in Dayton, was found guilty earlier this year for loitering to engage in solicitation, according to court records. >> Read more trending news Daniel P. Williams, 40, of Huber Heights, was found guilty in late August after pleading guilty to a misdemeanor count of loitering, according to Dayton Municipal Court. Williams’ employer is listed as Arrowbrook Baptist Church in Xenia in both court record and the police report. The church’s website also lists Williams as its pastor. Attempts to reach Williams by phone  were unsuccessful. Williams was originally charged with a second count of loitering and a third count of soliciting. Both were withdrawn upon his guilty plea, according to Dayton Municipal Court.  The violation happened at around noon Aug. 17, according to Dayton police. Williams was sentenced to 60 days in jail, with all 60 days suspended. He will be on probation for one year, according to court records.
  • The Oklahoma Senate approved a bill Friday that will cut funding to most state agencies and will spend cash reserves to help plugging the $215 million budget hole. Lawmakers were forced to fix a budget shortfall after they failed to pass a broad package of tax increases. The plan would impose cuts of about 2.5 percent on most agencies to make up for expected revenue lost from an unconstitutional cigarette tax the Legislature approved in May. The rest of would be filled by using one-time money, including savings accounts. Lawmakers returned to the Capitol on Sept. 25 for a special session to fix the budget and find longer-term solutions to chronic shortfalls that have forced deep cuts to agencies and services for three consecutive years.