As I’m sure you all have heard by now, a federal judge in Texas ruled on Friday, December 14th, that the entire Affordable Care Act was unconstitutional because the individual mandate had been reduced to zero. Some believe this will be reversed on appeal. Others feel validated by the ruling. While the law remains intact for the next few months, it is worth looking at what an ACA repeal would mean to your reimbursement.
Repealing the ACA Today
First, states that expanded Medicaid to a larger portion of their population will be fully on the hook for funding these plans. Some states have clauses that Medicaid will restrict back to pre-ACA levels if the law is repealed. Other states, such as Montana, are already determining how to fund the current expansion. States where Medicaid has not expanded will not see a change.
In states that did expand Medicaid, a restricting of the eligibility for the program will lead to an increase in the number of uninsured patients seeking care. These patients will likely not be meeting with primary care physicians, but instead will be heading to your emergency department. As well as ED volume increasing, HBI research shows that the amount of uncompensated care that your organization is giving away and writing off will also increase. Preparing for this and attempting to set up payment plans for uninsured patients will be incredibly important.
At the same time, patients getting insurance through the marketplace exchange will also lose their coverage. Adults under the age of 27 that are still under their parent’s insurance will also suddenly be uninsured in a majority of states. The Trump administration has given these people some options over the past year. Short term insurance plans, with a length of up to 364 days are available. This coverage does not cover the 10 essential health conditions that the ACA says all health insurance plans must cover, but that requirement will also disappear, so these may offer a cheap, spotty way patients can get covered.
The requirement that insurers cover all patients, no matter their current health condition, also known as the preexisting conditions protection will also sunset. Because of this, it will be even more important to check the medical necessity and authorization numbers for all services being provided. Informing patients about what is and is not covered with their insurance will be extremely helpful. Providing patients with accurate price estimates for their services will also help. Though patients will have access to your charges now because of the CMS’s price transparency requirements, that does not help them calculate their actual costs on their own.
Less patients with insurance means less claims being sent to payers, and less denials. It also means more effort in following up with patients to collect. Redistributing your back-end staff to follow the trend will be necessary but collecting from patients on the front end will alleviate some back-end stress. Charging a certain amount for nonemergent services in the ED and deferring the services for those that are not willing to pay should help you stay away from some amounts of avoidable bad debt.
As with all legal proceedings, the actual resolution of whether the ACA is constitutional will take months, if not years. Heck, we may even have the Supreme Court weighing in again. Any number of things could change before then. Congress could pass some sort of mandatory coverage for people with preexisting conditions. Medicaid-For-All could force states or the federal government to provide coverage for everyone that needs it. Repeal-And-Replace could attempt to remove the ACA again. As for now, it can be helpful to remember what changes have occurred because of the ACA and how that disappearing would change things at your organization.
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