I have a friend that manages an office for 7 or 8 doctors. He told me that under the new ACA guidelines that if the patient doesn’t pay the portion in that they are supposed to that the doctor’s office has to pay it. Now I’m not exactly sure what he was talking about but I’ll get him to tell me more and report back on it. It sounded like the bottom line is that doctors will be turning away a lot of patients that are covered by the ACA.
“...the doctor’s office has to pay it.”
Now that’s redistribution of wealth in action!
Good for him. His "joblock" was costing him 60-70 hours per week. Now he can be a philosopher-poet.
True, although I would state it a little differently, more mechanically. Patient arrives at Doc’s office and the doctor renders (let us say routine) services under the presumption that the patient is insured. Doc submits his bill to insurance provider.
Note: the payment to the Doc barely covers his costs, if even. Some of the reimbursement rates are completely ridiculous, $13.27 or $23.19 or equivalent small sum for what the Doc would charge $75 or $90 or $125 for. If you don’t believe me, go look at a typical Medicare bill and the reimbursements. Almost not worth submitting the bill in the first place. A different but not irrelevant issue.
Ins provider checks to see that patient is paid up as far as his/her copay or premium on the day they are supposed to cut the check to the doc. If patient has not paid, then the doc gets no payment.
In other words, the doctor is not only agreeing to treat patient as essentially no or negative profit on the basis of apparently valid-looking papers, the doc is also taking a risk that the presumption of valid patient insurance is false, or ineffective. The doctor has no way of checking the validity of the patient’s ins to the point of payment at the time he renders service. Patient could very well have good-looking ins ID or whatever papers are nominal, but if he/she has ceased premium payments, the papers could be later deemed void.
Not quite the issue and I can only speak about those covered under Blue Cross Texas Obamacare/Exchange plans.
Patient comes in in January and provides coverage info reflecting OE plan. BC contacted and they verify what coverage may be, although info not yet in their system. Pt pays co-pay, doctor sees and pt leaves. Pt returns in February, March, April and May. BC pays claim for January but not until March or April. BC still hasn’t paid anything on claims for February-May because they have no record of premium payment - even for January.
So BC deducts amount they paid for January from doctors checking account (electronic fund transfers only allowed). Now doctor can try to collect total outstanding balance from patient.
Patient B is in a different type of OE plan. Same as above but doctor receives a letter from BC saying that if the patient did have coverage, the amount allowed for the services provided would be $X and so that is all the doctor can collect minus any co-pay already paid, not their total private pay fee.
Patient C is in yet a different type of plan. Same as above but doctor receives a letter from BC saying that if the patient did have coverage, they are unable to verify but the type of the plan the patient was enrolled in does not allow the collection of any payment (think Medicaid type of plan).
Regardless of which type of plan the patient is in, unless it is a traditional BC plan, the doctor is screwed. And yes, IMO, they are wise to turn away patients covered by ACA or get totally out of the network and see the patient as private pay, albeit at a reduced rate.
The CHIP and/or OE program run by United Behavioral Health is yet another animal and is a type of a Medicaid program which is paid by state funds. Patients do not pay a co-pay at all or deductible and the doctor is paid at a rate much higher than the normal UBH contract rate for providers who see patients with a high deductible and/or co-pay under plans provided by their employer.
In short, Texas taxpayers are taking it on the chin for patients covered by CHIP plans or Medicaid replacement plans when the patients are covered under a plan through United Behavioral Health.
All of the doctor clients I have who are scattered all over Texas accept anyone through the ACA program any more unless they want to be seen as private pay and pay in full at the time of their visit.