What King v. Burwell Could Mean for Medical Practices

In June, the U.S. Supreme Court will rule on King v. Burwell, which challenges whether tax subsidies helping Americans purchase health insurance through healthcare.gov, the federal health insurance exchange, are valid.

In this video, Anders M. Gilberg, senior vice president for government affairs with the Medical Group Management Association (MGMA), examines what a decision invalidating those subsidies would mean for medical practices nationwide. He also offers advice to practices on what they can do-regardless of the pending decision-to ensure they get paid for seeing patients, regardless of the patient’s insurance coverage.

READ MORE: 5 ways the Affordable Care Act will transform primary care practices 

Transcript of video

Well, it's impossible to predict what the Supreme Court will decide. What's interesting about the rollout of the Affordable Care Act is that in addition to the rollout of the exchange, there's been a significant expansion of Medicaid. King v. Burwell will not affect the Medicaid expansion.

From our discussion with [MGMA] members, in those states that have expanded Medicaid, that's where a lot of the access to physician problems have occurred as opposed to those patients who are accessing physicians through insurance they purchased on the exchange. There's two different issues there to be clear about.

Need a new EHR for ICD-10? | Download our guide to find out

If the court rules against the government, what will ultimately happen is that the subsidies for patients who've purchased insurance on non-state based exchanges will be removed and could potentially disrupt the insurance market in those states. Our recommendation to practices is that they shouldn't jump to any conclusions or take any immediate actions until we see what Congress may do to intervene and mitigate the disruptions which would occur based on that Supreme Court decision.

That said, there are some really basic, core things, regardless of what happens with the Supreme Court, that practices still need to do, especially with patients who've purchased insurance on the exchange.

Most of the insurance purchase on exchanges has been of a high-deductible nature: $3,000 or $4,000 of a deductible. For those patients, it still very similar to a cash-based system when operating under such high deductibles. What's been most important in the conversations we've had with practices is that practices have to have a robust eligibility verification process prior to the patient coming into the practice. That is important, not only if they have a high-deductible health plan, but also if – for whatever reason – the Supreme Court decides one way or another, that the insurance the patient has is discontinued or disrupted, it will be more important than ever for the practice to verify the eligibility of that patient to make sure when they are having a conversation with the patient, they can tell what the patient is insured for, what the deductible is, or if their insurance is going to lapse.