Sheila Lawless is the office manager at a small rheumatology practice in Wichita Falls, Texas, about two hours outside of Dallas. She makes sure everything in the office runs smoothly – scheduling patients, collecting payments, keeping the lights on. Recently she added another duty–incorporating the trickle of patients with insurance plans purchased on the new Affordable Care Act exchanges.

Open enrollment doesn't end until March 31, but people who have already bought Obamacare plans are beginning to use them. “We had a spattering in January—maybe once a week. But I think we're averaging two to three a day now,” says Lawless.

That doesn't sound like many new customers, but it's presented a major challenge: verifying that these patients have insurance. Each exchange patient has required the practice to spend an hour or more on the phone with the insurance company. “We've been on hold for an hour, an hour and 20, an hour and 45, been disconnected, have to call back again and repeat the process,” she explains. Those sorts of hold times add up fast.

In the past, offices have been able to make sure patients are insured quickly, by using an online verification system. But for exchange patients, practices also have to call the insurer to make sure the patient has paid his premium. If he hasn't, the insurance company can refuse to pay the doctor for the visit, or come back later and recoup a payment it made.


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That's because of a provision of the law that gives exchange patients who neglect to pay their premium a “grace period” of up to 90 days. During the first 30 days, insurers have to pay any claims incurred by the patient. But for the next 60 days, nothing is guaranteed. If the patient visits the doctor, the insurer can “pend” the claim – that is, wait to pay the doctor until the patient pays his premium. At the end of the 90-day grace period, if the patient has not paid the premium, the insurer can cancel the coverage and refuse to pay the pended claims, or recoup the payments it's already made.  And that puts the doctor's office at risk.

So Lawless is checking first with the insurer to make sure that everything is in order before proceeding with the visit. If the premium has not been paid, Lawless gives the patient the option of rescheduling the appointment or paying in cash and then applying to his insurer for the payment.

“Most small practices run lean and mean – you've got one or two people to do this process plus do their other job duties that day as well, which is tend to the patients in front of them,” says Lawless. To manage the new workload, she's had other staffers, including nurses, step in to answer the phone. And that means longer hours, more overtime, and higher overhead expenses. And then there's the plain old annoyance factor.

“You call in and you hit option prompts and you get to listen to no less than an hour of Blue Cross Blue Shield intro music. I could sing you the tune, that's how often I've had to listen to it,” she says. “My staff said yesterday, it's a sad shame within their prompts you can't pick your music as well. If you're going to have to wait that long, at least let us listen to what we want to listen to!”

Blue Cross Blue Shield in Texas is the only insurer offering exchange plans in Wichita Falls. Dr. Dan McCoy, the company's chief medical officer, says part of the problem was the health law's compressed timeline.

“Clearly at the end of December there were a significant number of members that enrolled and it's taken some time to work through that volume in membership,” explains McCoy. “And we know this is a new day in the transformation of American health care. So it's going to take a little bit of time to work through that.”

Health Care Service Corp., which owns Blue Cross Blue Shield of Texas, has tried to address the situation by adding another 600 employees at its call center to handle the influx of calls and by extending business hours. McCoy has also been working directly with the Texas Medical Association to work out the kinks.

Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association in Washington, D.C., a trade group for practice administrators, says the real problem is that signing up for coverage on the exchange isn't as simple as the White House has made it sound.

“What we've found is that messaging out of the [Obama] administration right now that's aimed at the public, it tends to oversimplify the complexity of what it takes to get covered on the exchanges,” says Gilberg. “Just because you enrolled in coverage doesn't mean your coverage is effective.”

Even if patients pay their premium right away, it could be up to six weeks before their coverage actually starts. To have insurance start at the beginning of a month, the coverage generally must be purchased by the middle of the previous month. A plan purchased on Feb. 14 would be effective March 1. But a plan purchased on Feb. 16, for example, would not become effective until April 1. Go to the doctor before then, and your insurer doesn't pay.

“It's not a surprise that given the subtle nuances and differences of what these exchange products are, that you're in a gray area right now where there's a little confusion on the patient side and the practice side. And I think that's what we're seeing a lot of right now,” says Gilberg.

For a brand new program, that's to be expected, he adds. And it doesn't mean the exchange isn't working. The real test will be what happens in April, when open enrollment ends and everyone who has purchased a plan offered through the health law's online exchanges plan is clearly covered.

In the meantime, Lawless offers this advice to patients who have bought plans on the exchange: “If you pay your premium prior to [visiting the doctor], print that out and bring it with you because that will certainly save all a lot of grief.”