What new insurance provisions on preventive care mean for your practice

A column about keeping your practice in good health

By Victoria Stagg Elliottis a longtime staff member. She covered practice management issues and wrote the "Practice Management" column from 2009 to 2013. She also covered public health and science from 2000 to 2009. Posted Nov. 29, 2010.

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The health system reform law requires an increasing number of insurance plans to cover 100% of widely accepted preventive health care without co-pays or coinsurance. Experts say this will complicate collecting the appropriate patient portion. But some preparation of medical office staff combined with patient education may simplify the situation.

"It used to be that only the insurance or billing staff needed to really know about benefit changes," said Mary Pat Whaley, author of The Smart Manager's Guide to Collecting at Check-Out and owner of "Everybody in the practice needs to have a heads-up about these changes because it touches so many parts of the practice."

The Patient Protection and Affordable Care Act states that private health insurance plans, as well as Medicaid and Medicare, must fully cover most preventive care. The formal definition of what is 100% covered is preventive care given an "A" or "B" grade by the U.S. Preventive Services Task Force, vaccinations recommended by the Advisory Committee on Immunization Practices, and other services called for by the American Academy of Pediatrics' Bright Futures. The mandate does not apply to grandfathered plans, defined as those that have not changed significantly since the health reform bill was signed.

Determining which plan a patient has "is one more layer of complexity to the billing cycle," said Nancy Babbitt, administrator of Roswell Pediatric Center in Alpharetta, Ga.

An additional wrinkle is that co-payments and coinsurance may apply to patients with full coverage of preventive services if a problem-oriented service is performed during the same visit. For example, a patient may come in for cholesterol screening, which may be fully covered. If a lipid disorder is detected and needs to be treated, however, the patient would be required to pay usual co-payments and coinsurance.

Those working with medical practices on this issue advocate looking at the eligibility and benefits verification process to ensure that money is collected from patients who are supposed to pay, but not from those who are not.

"Processing a refund can be just as expensive as issuing a statement," Whaley said.

Some experts suspect that eliminating a patient's financial contribution for some services may increase demand, and practices need to think how they may meet that. For instance, some practices may find it effective to focus on sick visits on Mondays to deal with demand from the weekend. The middle of the week, which tends to be lighter on acute visits for most practices, may be a better time to schedule preventive services.

"You need a schedule that will ideally have the best balance to meet the acute needs and the preventive needs," said Elizabeth Woodcock, principal of Woodcock & Associates, a physician management and consulting firm in Atlanta.

Experts advocate teaching patients about when a co-pay or coinsurance is required. Employers and health plans should inform patients whether they have a grandfathered plan and what benefits they have. This does not mean patients will necessarily know this information. But the hope is that additional patient education provided by the practice will reduce the chances of patients being surprised if they have to pay out of pocket for visits they thought were fully covered.

"The more we talk about it, the better it will be for everybody," Babbitt said.

Rockwood Clinic in Spokane, Wash., started handing out information sheets a few months ago to patients when they joined the practice or received preventive services. The sheets state that if a problem-oriented service is provided during a preventive visit, the appropriate charge will be assessed.

"The practice needs to take a proactive approach to educating patients so that there is no surprise," said Glen Stream, MD, Rockwood's chief medical information officer and president-elect of the American Academy of Family Physicians.

Patients will need to know what a fully covered preventive service is. Experts advocate identifying the most common situations a practice faces and develop responses. For some doctors, the most common issue will be explaining what vaccines are fully covered. For others, the need to explain details of breast cancer screening will be more critical.

"It's overwhelming, but focusing on your specialty would be key," Woodcock said.

Despite the initial complexity of this transition, experts believe the situation will simplify as more health plans lose grandfathered status and full coverage of these preventive services becomes more common. About 18% of large group plans and 30% of small ones are expected to relinquish grandfather status in 2011. The federal government expects the numbers to grow to 45% and 66%, respectively, by 2013.

More guidance is expected from the federal government on how this part of health system reform should be implemented. The Interim Final Rule for Group Health Plans and Health Insurance Issuers was published by the U.S. Dept. of the Treasury, Dept. of Labor and Dept. of Health and Human Services in the July 19 Federal Register. Additional rules are expected.

Several medical societies, including the American Medical Association, have weighed in on the rule-making process. The AMA is calling for regulations that prevent insurers from shifting the cost formerly paid by patients for preventive services to physicians. In addition, the regulations should be in line with the AMA's CPT preventive medicine service codes, guidelines and instructions.

Victoria Stagg Elliott is a longtime staff member. She covered practice management issues and wrote the "Practice Management" column from 2009 to 2013. She also covered public health and science from 2000 to 2009.

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