Affordable Care Act - need clarification from the insurance gurus

[ted_kennedys_liver]

Thanks guys. Good info and very proud of all off you

[Bonehead]

I snapped this pic yesterday. I am a physician liaison and go into more than a dozen doctors office per week and I'm seeing this more and more!

[BrianL]

I snapped this pic yesterday. I am a physician liaison and go into more than a dozen doctors office per week and I'm seeing this more and more![ATTACH]588497[/ATTACH]

If policies on exchange are blue cross, how does it matter where they were bought?

[Shane]

If policies on exchange are blue cross, how does it matter where they were bought?

Because of a couple of things.... Obamacare policies don't pay physicians as much, so many docs aren't able to accept it and stay in business. If they do accept it, then there is still a lot of uncertainty about whether someone who tried to buy an Obamacare policy being actually enrolled and covered. The Obamacare website and whole system is such a humongous mess that there is no way to know for sure yet if someone has coverage or not. The docs could end up providing care, sending a bill to the insurance company and then finding out there the patient didn't have coverage after all, due to the website mess.

[Bonehead]

If policies on exchange are blue cross, how does it matter where they were bought?

Real reason is there is a 90 day grace period on payment of premiums to try and get more people to sign up. If that premium is not paid in full after the 90 day sign up date the the insurance company has the right (and will) not pay for services rendered. It's a bad deal all the way around.

[gspbrad]

Real reason is there is a 90 day grace period on payment of premiums to try and get more people to sign up. If that premium is not paid in full after the 90 day sign up date the the insurance company has the right (and will) not pay for services rendered. It's a bad deal all the way around.

Grace period is a concern, but not for the question you answered. Prompt pay regulations will kick in before 90 days.

When calculating a subsidy, Geographic Rating Areas come into play. Payers are looking at aligning provider networks to GRAs. I posted in a previous response, the largest differentiator moving forward will be Price. Product structure (type & # of benefits) and Service have in large part been eliminated. Payers are trying to get to the lowest price available against targeted risk factors. They are building sub networks of providers from within their holistic networks. Not all providers are willing to join a sub network - that's why they may refuse to accept ACA coverage plans.

[Joshua Flournoy]

I talked to a surgeon friend of mine today. He is seriously contemplating either retiring or going to a cash only business model to stay in business, because the reimbursement rates through Medicare and now the ACA don't leave much profit margin at all.

So if you like your policy, you can keep it (unless the ACA requires your insurer to cancel it).

And if you like your doctor, you can keep him/her (unless the ACA puts him/her out of business).

Gotta love big government control freaks.

Or if your new ACA mandated policy doesn't include your doctor in it's coverage network, which is highly likely.

[Bill]

Affordable Care Act - need clarification from the insurance gurus

As I understand it, few if any doctors will accept patients with policies through the exchanges because the payment schedule for services is below their cost to provide them. You can't loose a little money on each patient and make it up on volume- unless your office visits are no longer than 10 minutes- which they don't want to do.

Some doctors have joined local or regional groups to minimize their regulatory and I durance overhead, and may be forced to accept those exchange patients by contractual commitments. Expect long wait times for appointments and short appointments.

Unless of course you have an exchange policy and the first 5 or 10 thousand dollars is out of pocket. If they can charge their regular fees in advance of the appointment, expect to pay by credit card or cash BEFORE the appointment.

Where the ACA falls apart is if somebody can't afford the premium and the government pays all or most through a tax credit ( we pay it since the govt has no money) how will that person pay a $300 out if pocket? In the ER a $2,000+ in advance payment? A payday advance loan in the doctor's office

[ram6256]

The other issues with this that is not being discussed here is the shift from treating illnesses to "preventing them. There is a significant change in reimbursement in doing physicals/annual exams (they pay very well for these) to reduced reimbursements for treating actual illness/helath problems.
Roy

[rubydog]

The other issues with this that is not being discussed here is the shift from treating illnesses to "preventing them. There is a significant change in reimbursement in doing physicals/annual exams (they pay very well for these) to reduced reimbursements for treating actual illness/helath problems.
Roy

So what you are saying is that the AHCA is paying the doctors good rates for physicals etc and not paying them well for treatment?
Am I reading you right?

[ram6256]

That is correct. Not only are the annual exam reimbursed better, THEY ARE REQUIRED. The provider that does not follow the RECOMMENDED/MANDATED guidelines will face fines and even expulsion from the ranks of providing care to that companies clients. This would affect all the companies he deals with since the national reporting lists this.
Roy

[rubydog]

That is correct. Not only are the annual exam reimbursed better, THEY ARE REQUIRED. The provider that does not follow the RECOMMENDED/MANDATED guidelines will face fines and even expulsion from the ranks of providing care to that companies clients. This would affect all the companies he deals with since the national reporting lists this.
Roy

Actually I had already been told this by a congressman friend of mine. His name is Dr. Dan Beneshek MD. and is in Iron Mountain Michigan. When I told people that the doctors could be fined very severely through the AHCA they all kinda thought I was making it up. I just wanted a PA t say so...

Logic says that even if they pay more for a check up the preponderance of billing will still be done through treatment and not preventative. Most people go to the doctor several times a year for illnesses and treatment and not checkups.

It all goes back to what is affordable to the patient and not the doctor. It still costs money and time away from work to go.