MGMA: Plan Identifier Not as Easy as Envisioned
Implementation of a national health plan identifier under the Affordable Care Act, while a worthwhile effort, is not a slam-dunk process, the Medical Group Management Association contends.
Implementation of a national health plan identifier under the Affordable Care Act, while a worthwhile effort, is not a slam-dunk process, the Medical Group Management Association contends.
“If properly developed and implemented, incorporating an HPID into the healthcare system is an excellent opportunity to streamline an important part of the claims revenue cycle, defined in medical group practice as the cycle from registration of the patient to the account being paid,” MGMA notes in a comment letter to the Centers for Medicare and Medicaid Services.
However, there are obstacles to overcome before the progress, the association warns, starting with the ambiguous term “health plan.” The proposed rule permits a health plan to enumerate itself with just one identification number, but insurers often have multiple plans with different benefit levels and fee schedules. “Without knowing which entity performs each role in the revenue cycle, physician practices experience difficulties in processing transactions, reconciling claims and posting payments, all contributing to patient dissatisfaction and confusion,” according to the letter.
Rental agreements between health plans further complicate the process, MGMA asserts. “Health plan A may ‘rent’ a benefits package to health plan B for such services as mental health, vision, physical therapy and others. For many providers, it appears as though the patient is ‘out of network,’ but they are actually still in network, just party to a rental agreement. In some cases, even though the provider has an existing contractual relationship with health plan A, it does not with health plan B. The remittance coming back from health plan B is confusing to providers as in many cases they cannot identify the health plan and must manually decipher who the plan is, the contractual agreement between health plan A and health plan B, and any contractual reduction of the claim amount.”
The association in its 27-page letter goes into considerable detail on fixes to a multitude of issues that could arise. The group also comments on other elements of the proposed rule, including extension of the ICD-10 deadline and additions to national provider identifier requirements. The letter is available here.
“If properly developed and implemented, incorporating an HPID into the healthcare system is an excellent opportunity to streamline an important part of the claims revenue cycle, defined in medical group practice as the cycle from registration of the patient to the account being paid,” MGMA notes in a comment letter to the Centers for Medicare and Medicaid Services.
However, there are obstacles to overcome before the progress, the association warns, starting with the ambiguous term “health plan.” The proposed rule permits a health plan to enumerate itself with just one identification number, but insurers often have multiple plans with different benefit levels and fee schedules. “Without knowing which entity performs each role in the revenue cycle, physician practices experience difficulties in processing transactions, reconciling claims and posting payments, all contributing to patient dissatisfaction and confusion,” according to the letter.
Rental agreements between health plans further complicate the process, MGMA asserts. “Health plan A may ‘rent’ a benefits package to health plan B for such services as mental health, vision, physical therapy and others. For many providers, it appears as though the patient is ‘out of network,’ but they are actually still in network, just party to a rental agreement. In some cases, even though the provider has an existing contractual relationship with health plan A, it does not with health plan B. The remittance coming back from health plan B is confusing to providers as in many cases they cannot identify the health plan and must manually decipher who the plan is, the contractual agreement between health plan A and health plan B, and any contractual reduction of the claim amount.”
The association in its 27-page letter goes into considerable detail on fixes to a multitude of issues that could arise. The group also comments on other elements of the proposed rule, including extension of the ICD-10 deadline and additions to national provider identifier requirements. The letter is available here.
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