Revenue Cycle Management Blog | GroupOne Health Source

Insurance Exchanges & Your Practice Part 1: What to Expect

Written by Kaitlyn Houseman | October 9, 2013

By now you have probably read a number of articles and blog posts regarding the exchanges created by the Patient Protection and Affordable Care Act (ACA).  In case you have been hiding under a rock the past couple of days, the federal government opened the exchanges on October 1st to Americans which will offer them four tier levels of health insurance plans.  The lower monthly premiums will come with substantially higher deductibles however the exchanges will ultimately provide Americans with healthcare plans at a low cost.  On top of the low costs, some Americans will be eligible for tax credits and subsidies.

Now that you’re up-to-date, let’s focus on what this means to your practice and your revenue cycle management.

PRO: The plans will likely bring you more patients

CON: They will be confused about their coverage and their financial obligations

Patient Responsibility

As mentioned earlier, the lower-tier, lower premium plans will have high deductibles.  Do your patients have the money set aside for the deductible or other out-of-pocket costs for their healthcare? 

Confirming eligibility on every patient will become even more important in the coming months. 

Under the new HIPAA electronic standards, each patient’s eligibility should be available to you within 20 seconds of your request.  To prepare your practice make sure your front office staff is communicating the changes to the patients and informing them of their financial responsibility in accordance to your practice’s policies.

The Grace Period

In order to commence coverage, an initial premium payment for the plan purchased is required.  However, there is a three-month grace period to make up a missed premium payment before being dropped from a plan.  During those three months the patient can still seek services from your practice. 

The insurer will continue to pay claims during the first 30 days after nonpayment of the premium.  Once day 31 arrives, expect insurers to not process any new claims for services that you have provided. 

If a payment is made during day 31 and 90 of the grace period, it can be taken back from you.  The patient will likely appear as “eligible” when financial clearance is requested throughout the grace period. 

The Centers for Medicare and Medicaid Services (CMS) has advised insurers to “notify all potentially affected providers as soon as practicable when an enrollee enters the grace period, since the risk and burden are greatest on the provider.”  Hoping for the best means that practicable is going to be day 31 and not day 59 of that grace period.

Prepare Your Staff


The grace period can create stress on your staff and your revenue cycle if you aren't prepared.  For any services provided during the grace period that the insurer will not cover, your only option to get paid is to collect from the patient. 

With this in mind, make sure your practice is checking a patient’s coverage status at each visit by asking the insurer if the patient is current on their payment.



Written by Kaitlyn Houseman, GroupOne Sales Coordinator