Anthem helps physicians avoid risk of 90-day premium grace period

Frustrating as it may be to wade through paperwork for insurance claims, tracking down a patient months after rendering a service to collect payment would certainly be worse.

And that is the predicament in which many physicians may find themselves. New reports indicate that while many people signed up healthcare insurance through the insurance exchanges created under the Affordable Care Act (ACA), not all have paid the premiums that are necessary to maintain their coverage.

The ACA allows the consumer to keep coverage for 90 days after a missed premium payment. In the first month, the insurer will reimburse claims. But in the second and third months, the charges are listed as pending until a premium payment is made or until the plan is cancelled. In case of cancellation, physicians will have to bill the patient directly for the services rendered and then wait for payment.

But Anthem Blue Cross Blue Shield has announced a new plan to verify a patient’s insurance status at the time of service, thereby taking the guesswork out of treating patients covered by a new exchange plan. The Availity, or Electronic Data Interchange (EDI) program allows providers to find out if patients are in their second or third month of their grace period, or whether they have missed any payments.

Claims for treating patients who are in their second or third month of the grace period will be returned during a benefits and eligibility transaction as “Inactive-Pending Investigation,” whereas a patient in the first month of the grace period will appear as an active member.

Anthem says it will not consider a provider’s refusal to treat patients listed in the second or third month of their grace periods as a breach of contract, but that physicians should carefully consider a patient’s condition before refusing treatment.

Clare Krusing, deputy press secretary for America’s Health Insurance Plans, says the organization does not track information on individual insurance plans and isn’t aware of programs like that created by Anthem becoming part of a larger trend. However, organizations like the American Medical Association have cried foul over the likelihood that the grace period and other ACA provisions will increase the amount of uncompensated care that physicians will have to bear.

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