Keeping up with Insurance Complexities as the Affordable Care Act Turns Five

By Bill Bunker, Executive Vice President, SCI Solutions

The Affordable Care Act turned five this past week. While opinions are mixed, the numbers are clear – healthcare coverage is expanding:

  • 16.4 million: Number of previously uninsured Americans who have gained coverage under the law, dropping the uninsured rate from 20.3 percent to 13.2 percent.
  • 2.3 million: Number of previously uninsured young adults, ages 19-25, who have gained health insurance through the under 26 provision, which allows them to stay on their parents’ plan. This dropped the uninsured rate for young adults from 34.1 percent to 26.7 percent.

With the insured patient population increasing, it is crucial for practices to understand their patient’s insurance plan to determine whether a authorization is required prior to their visit. Without the authorization properly in place, practices risk not being compensated for care provided.

However, the expansion of insurance coverage has created a complex maze of payer plans and rules. Practices have to sift through pages of information on payer sites to determine when authorizations are required and what type of information is needed. To make matters more confusing, patients with unstable incomes often churn plans (fluctuating between Medicaid and unsubsidized private insurance), which means their coverage can change month-to-month.

Understanding these plan changes require detailed knowledge of authorization rules across a large number of payers.  Many practice staff are overwhelmed with other priorities and do not have time to maintain this knowledge base, leading to errors and lost payments.

How has the Affordable Care Act affected your practice and ability to successfully obtain authorizations? Share your comments below.

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