New Affordable Care Act measure gives patients more rights and help with their health insurance and health choices, but what does this newly expanded provision mean to healthcare providers?

The Affordable Health Care Act was signed into law in March of this year. It seems to be as rough a draft as the ARRA stimulus provisions in that they are continuing to be expanded and defined as they go. The new features expanded/added last week (see the official July 22 News Release) involve a desire to put patients more in charge of their healthcare and to give them better protection by giving them rights of appeal in claim and procedure denials. Per the news release: “Consumers in NEW health plans in every State will have the right to appeal decisions, including claims denials and rescissions, made by their health plans.” The plan is that there will be a set of standards and “defined and impartial” appeals method for your patients allowing them access and help with knowledge and protocols to be able to ask and work options for both internal and external appeals processes. This new, expanded provision also grants, by application, $30 million for Consumer Assistance Programs to create or strengthen existing offices to help your patients appeal decisions made by their insurance companies as well as to help them decide on appropriate health plans and insurance options for them. The appeals standard looks to have come from the National Association of Insurance Commissioners (NAIC) and per the Fact Sheet (listed below) States are “encouraged” to adopt the NAIC external appeals laws as their State appeals laws before July 1, 2011. The combined effect of these enhanced patient protections and the NAIC appeals laws are roughly listed next.



What does this mean for your patients? (July 22 Fact Sheet that goes along with the above Press Release)

• Information and help with information and processing about health care insurance options, as well as internal and external audit options and processes. This would include tracking of consumer complaints and problems for strengthened enforcement.
• Quicker, emergency access to these procedures for emergency issues and experimental or investigational treatment needs).
• Patients can appeal to insurance companies for denied coverage of procedures or prescriptions you deem necessary for your patient, but the insurance company may not.
• Can have an external or “outside” (independent) appeal if not satisfied with internal insurance appeal (and per the Fact Sheet the health plan is to pay the cost of the external appeal).
• Decisions are to be binding; if the patient wins the health care plan is expected to pay.

On the downside for patients: it isn’t exactly spilled out and they are throwing more money out to the assistance programs and offices to increase their abilities, but it reminds me a lot of the Social Security offices and systems. I can see patients going into overworked, understaffed offices that want to help, and want to do so in a timely manner, but are just too overwhelmed. I can see “case workers” trying to help and follow up on as many people and problems as possible, but running into the same government oversight and red tape options as current Social Security Offices. I don’t mean to be a “Debbie Downer”, and the sun may be high, but the facts are the facts and current government program run options are as they are.

So, what does this mean for you as a provider of health care services?
Honestly, I cannot find links or mention anywhere of what this might mean for you as providers. I found that to be a bit lacking. The following is mostly conjecture on my part, but I give it so that you might consider or re-consider how you think about this and why you may want to think about this now rather than wait a year or two to feel its impact, first hand, in your office lives.

The Good:

• Your patients will be able to fight for the treatment options you feel will best help them and meet their needs, rather than helping the needs of the insurance company. You get to be a doctor again.
• Some things that you were not getting paid for (or were writing off entirely) before, you may be able to get paid for now. I get the feeling this will be a more likely option for hospitals than individual physicians and offices though (we’ll talk more in a minute in “The Bad”).

The Bad:

• You may not receive some insurance payments in a very timely manner as things will likely get “put on hold” probably during an appeals process.
• In hopes that patients can take things to an appeal for some, more, or all payment, they may try to withhold payment themselves until they try their luck with the appeals process (or under the pretense of going to the appeals process).
• You will probably be asked to give “back up” information to or for your clients including, but not only including: documentation of treatment, treatment plan, and follow-up; full case work or history and records request for said patient or visit cases; good documentation of all necessary information about the patient, the case, the need for medical necessity will likely need to be provided, per askance, etc. (You can feel the vibe of an EHR here can’t you?)
• Your current records (even giving the advantage that they are better than perfect) may not be enough, you may be required to write of notes or reports for these cases or you may even be required to be present at an appeal.

You can probably get the drift that this will be no walk in the park for you or your office. None of these items are mentioned or clarified in the existing document. I imagine that these are things that will come up and be future “tweaks” to the Affordable Health Care document (especially this newly expanded area of the document) as it continues to grow and be refined much like the ARRA stimulus changes that are ongoing and progressive for all areas of health IT in your office and its defined use.

So, why bring any of this up or mention it here and now? Well, forewarned is forearmed right? Now is the time to think about how you do things in your office, especially your office policies. Review them, see how you might enhance them as well as streamline them. Do you have an office policy? No? You should. What is an office policy? It is a policy on how you do things in your office. Often this is a policy that will be mostly handled and executed by an office manager with the billing and front desk staff, so that the doctors can do their doctoring and the office can take care of the "officing". By having an office policy in place you have a common framework for everyone in your office to work by. By sharing this policy with you patients and having them sign off on it as well, you make them not only partners in their health care, but you make them partners in your office, an office all bound by the same rules. One of the most important office policies you can have in place is a financial policy. This may be the best, most important thing that you consider, update or implement in your office this year. Better yet, as these “in process” changes continue to occur around you and begin to affect your office, you can feel confident that all of the staff, providers, and patients are on the same page, and it will help ease the transition (especially money-wise) as you proceed into a bright new health care future.