Revenue Cycle Management Blog | GroupOne Health Source

Insurance Exchanges & Your Practice Part 2: Reimbursement & Whether to Join

Written by Kaitlyn Houseman | October 11, 2013

What will happen with reimbursement now that the government has opened the insurance exchanges to Americans?  Well each state chose to either set up their own health insurance exchange, have the federal government set it up for them, or chose the joint-run option. 

"ObamaCare's State Health Insurance Exchanges can be run a number of different ways. States can build a health insurance exchange (HIX) on their own, partner with one or more other states, run a joint exchange with the Federal Government or have the Federal Government build and run the insurance exchange for them. All exchanges must be fully operational by January 1st, 2014. Only State's who build their own exchange receive full Government funding. States that set up their own exchange get to directly determine which companies can compete in their exchange and negotiate benefits and prices. In a federal exchange the U.S. Department of Health and Human Services (HHS) does this for them. In a join-run exchange any carrier meeting the minimum Federal and State requirements can compete in the exchange.”

Above is a map showing which states have opted for state based, federal based, or planning to partner exchanges. 

Determine your reimbursement rates and understand which insurers are offering products through the exchange and which are not.  From there you will want to determine if the fees are consistent with the products you already accept from that insurer. 

Some physicians may choose not to join exchange networks because they don’t want more patients but it could be difficult to opt out. 

“All-products” clauses may be in the contracts between physicians and insurers which would require them to accept any enrollee from any of the plan’s various products.  Some states ban the “all-products” clause however it may not apply if the insurer considers this a reconstitution of an existing product instead of a new product.  Other contracted providers will be added to exchange plans by some insurers via an addendum to their existing contract.  If so then the opportunity to negotiate new rates or new contract terms does not exist. 

Before choosing not to participate you may want to take into consideration those patients with existing insurances.  In order to maintain coverage for existing patients you would need to join the exchange.

To Join or Not to Join?

After considering the potential problems, should physicians join the exchange plans or opt-out?  It is a matter of evaluating your practice and how the new plan/product could benefit the practice and benefit existing or new patients.  Of course the current patient load is going to be a large factor but other aspects such as rates and structure of your practice need not be overlooked.