Healthcare Law Blog

An Unlikely Consequence

The Affordable Care Act (“ACA”) took a big leap forward this month with the opening of the federally-facilitated and state-operated Exchanges. Here in Kentucky, 70,467 people reportedly participated in pre-screenings to determine qualifications for subsidies, discounts, or programs like Medicaid on the Health Insurance Exchange’s first enrollment day, October 1, 2013. The ACA is eventually expected to provide health coverage to as many as 30 million additional Americans. So, why are hospitals across the nation slashing jobs? More >

Guidance on Mobile Medical Apps

Recently, the U.S. Food and Drug Administration (“FDA”) issued its much-anticipated final guidance for developers of mobile medical applications (“apps”). Apps run on mobile communication devices and can present unique problems not only to consumers, but also to providers who must walk a fine line between meaningful use requirements and HIPAA regulations regarding personal health information (“PHI”). More >

Does the Shutdown “Shut Down” Health Care?

The ongoing partial federal government shutdown that began on October 1, 2013, was initiated in an effort to defund the Affordable Care Act (“ACA”). Now, it seems that the shutdown is affecting everything but the ACA. More >

One Week In – Are Kentuckians Kynect-ing?

Everyone, especially those in the health care industry, waited with bated breath to see the nationwide launch of the online health insurance marketplaces on October 1st. The launch was plagued with website malfunctions and connectivity problems in some states, including Kentucky, but programs across the country welcomed people clamoring for a look at America’s new health care options. Proponents of the exchanges say that the glitches and initial setbacks are a good sign – the overwhelming traffic to the websites show that people are actively seeking health care. Health reform opponents see the initial problems as a sign that the exchanges, and health reform generally, are too cumbersome and complicated to implement effectively. More >

The Kentucky Board of Medical Licensure Adopts the Model Policy, cont.

Earlier this week, I began the discussion about the Kentucky Board of Medical Licensure adopting the Model Policy. While the Model Policy serves as a cautionary reminder of the hazards of social media, it also emphasizes the “enormous potential” social media has for both physicians and their patients. As telecommuting grows, electronic health records are implemented, and smart phones find their way into more and more physicians’ hands, it is obvious that shying away from technology is no longer an option. Nor should it be, as the use of social media really does have its benefits: reduced costs, improved physician-to-physician sharing and learning opportunities, the crossing of geographic boundaries, and a way to provide important information to the public. More >

The Kentucky Board of Medical Licensure Adopts the Model Policy

Over the summer, the Kentucky Board of Medical Licensure adopted the Model Policy for the Appropriate Use of Social Media and Social Networking in Medical Practice (“Model Policy”) that was issued by the Federation of State Medical Boards (“FSMB”). FSMB created their policy in 2012 to help medical boards provide guidance and education about issues related to social media. The FSMB Model Policy followed the American Medical Association’s (“AMA”) 2010 “Professionalism in the Use of Social Media” policy. Both incorporate the same principles, but the FSMB offers more concrete examples of conduct that should be avoided in social media activity. More >

UPS Denies Insurance Coverage of Spouses and Cites ACA as Reason

The United Parcel Service (“UPS”) recently made a big statement when they decided to drop 15,000 working spouses eligible for health coverage through their own employers from the UPS plan in 2014. The shipping conglomerate explained the change in a memo to its workers and repeatedly cited the Affordable Care Act (“ACA”) as the reason for the new policy. Rising medical costs “combined with the costs associated with the Affordable Care Act, have made it increasingly difficult to continue providing the same level of health care benefits to our employees at an affordable cost,” the memo stated. The new policy will not affect union workers, as their health benefits are already spelled out in labor contracts, but will apply to about a quarter of the UPS U.S. workforce. More >

The ACA Loophole Of Which Providers Should Be Aware, Part II

Earlier this week, we discussed the three-month grace period afforded to enrollees of qualified health plans (“QHPs”). To recap that article, the ACA requires that QHPs pay claims for the first thirty days of the grace period during which premium payment remains unpaid, but issuers may pend claims for the final sixty days of the grace period. If the balance remains unpaid, the issuer may deny any claims submitted within the final sixty days. More >

The ACA Loophole Of Which Providers Should Be Aware

Providers contracting with state health insurance exchanges may find themselves shortchanged for services provided due to a little-known loophole in the Affordable Care Act (“ACA”).

Under the ACA, an individual who fails to pay his or her insurance premiums has a three-month grace period before the policy is cancelled. Insurers, however, are only responsible for paying claims during the first month of that grace period. The ACA will allow exchange plan, also known as “qualified health plan” (“QHP”), issuers to pend claims submitted by providers during the last two months of a federally subsidized patient’s three-month grace period for premium payment delinquency. If the patient is terminated at the end of the three months, the QHP is free to deny all claims submitted for that patient within the final two months.

Here’s what providers can expect during the three-month grace period:

First month of delinquency:

• Claims are paid normally. The QHP treats this month as paid even if the enrollee is eventually terminated for non-payment.
• Providers are not notified of the patient’s delinquency.

Second and third months of delinquency:

• The QHP has the option to pend claims for services performed until the enrollee pays his or her outstanding premium balance.
• Providers submitting claims during these two months are notified of the potential that claims submitted for services performed for the enrollee may be denied.
• If the enrollee pays off the premium balance, providers’ claims are paid at that time.

Terminated after three months of delinquency:

• The QHP has the option to deny all claims for services performed in the second and third months of delinquency.

Note that the timing of an enrollee’s grace period is based upon the date when a service was rendered, not the date of claim submission. In fact, a patient may enroll in a different QHP during the next open enrollment period regardless of whether they have paid off an outstanding premium balance with their previous insurer.

Providers have the option to seek payment from the patient for denied claims, but a patient who is unable to pay their insurance premium is also unlikely able to pay a provider’s bill. Further, the legal action necessary to recover payment is a costly endeavor for any provider. Check back on Thursday for more information on this topic.

Services may be performed by others.

This article does not constitute legal advice.

Clarifying the “Two-Midnight Rule” and Part A Payments, cont.

Earlier this week, I discussed CMS’ final rule on the prospective payment for acute care and long-term care hospital inpatient services for fiscal year 2014. The final rule provides guidance to physicians on how to designate a patient as inpatient or outpatient and the impact of the designation on Medicare Part A or Part B coverage. This blog will discuss the two midnight rule. More >