Doctors’ Offices Get Put On Hold Trying to Find Out Who’s Insured

February 25, 2014

Sheila Lawless manages a small rheumatology practice in Wichita Falls, Texas, about two hours outside of Dallas. She makes sure everything in the office runs smoothly – scheduling patients, collecting payments, keeping the lights on. Recently she added another duty — incorporating the trickle of patients with insurance plans purchased on the new Affordable Care Act exchanges.

Open enrollment doesn’t end until March 31, but people who have already bought Obamacare plans are beginning to use them. “We had a smattering in January—maybe once a week. But I think we’re averaging two to three a day now,” says Lawless.

That doesn’t sound like many new customers, but it’s presented a major challenge: Each exchange patient has required the practice to spend an hour or more on the phone with the insurance company. “We’ve been on hold for an hour, an hour and 20, an hour and 45, been disconnected, have to call back again and repeat the process,” she explains. Those sorts of hold times add up fast.

In the past, offices have been able to make sure patients are insured quickly by using online verification systems run by the insurance companies. But for exchange patients, offices also have to call to make sure the patient has paid the premium. If it isn’t paid, the insurance company can refuse to pay the doctor for the visit, or recoup payments already made.

That’s because of a provision of the law that gives exchange patients a grace period of up to 90 days to pay. During the first 30 days, insurers have to pay any claims incurred. But for the next 60 days, nothing is guaranteed. If a patient visits the doctor, the insurer can “pend” the claim – they can wait to pay until the patient pays his premium. At the end of the 90 days, the insurer can cancel the coverage and refuse to pay the pended claims, or recoup payments already made. That puts the doctor’s office at risk.

So Lawless checks first with the insurer to make sure that everything is in order before proceeding with a visit. If the premium has not been paid, Lawless gives the patient the option of rescheduling the appointment or paying in cash and then applying to the insurer for reimbursement.

“Most small practices run lean and mean – you’ve got one or two people to do this process plus do their other job duties that day as well, which is tend to the patients in front of them,” says Lawless. To manage the new workload, she’s had other staffers, including nurses, step in to answer the phone. And that means longer hours, more overtime and higher overhead expenses. And then there’s the plain old annoyance factor.

“You call in and you hit option prompts and you get to listen to no less than an hour of Blue Cross Blue Shield intro music. I could sing you the tune, that’s how often I’ve had to listen to it,” she says. “My staff said yesterday, it’s a sad shame within their prompts you can’t pick your music as well. If you’re going to have to wait that long, at least let us listen to what we want to listen to!”

Blue Cross Blue Shield of Texas is the only insurer offering exchange plans in Wichita Falls. Chief Medical Officer Dr. Dan McCoy says part of the problem is the health law’s compressed timeline.

“Clearly at the end of December there were a significant number of members who enrolled and it’s taken some time to work through that volume in membership,” McCoy says. “And we know this is a new day in the transformation of American healthcare. So it’s going to take a little bit of time to work through that.”

Health Care Service Corporation, which owns Blue Cross Blue Shield of Texas, has tried to address the situation by adding another 600 employees at their call center to handle the influx of calls, and by extending their business hours. McCoy has also been working directly with the Texas Medical Association to work out the kinks.

The real the problem is that signing up for coverage on the exchange isn’t as simple as the White House has made it sound, according to Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association in Washington DC, a trade group for practice administrators.

“What we’ve found is that messaging out of the [Obama] administration right now that’s aimed at the public, it tends to oversimplify the complexity of what it takes to get covered on the exchanges,” says Gilberg. “Just because you enrolled in coverage doesn’t mean your coverage is effective.”

Even if the patient pays the premium right away, it could be up to six weeks before the coverage actually starts. The middle of the month is a key date. A plan purchased on Feb. 14 would be effective March 1. But a plan purchased on February 16, for example, would not become effective until April 1. Go to the doctor before then, and your insurer doesn’t pay.

“It’s not a surprise that given the subtle nuances and differences of what these exchange products are, that you’re in a grey area right now where there’s a little confusion on the patient side and the practice side. And I think that’s what we’re seeing a lot of right now,” says Gilberg.

For a brand new program that’s to be expected, he adds. And it doesn’t mean the exchange isn’t working. The real test will be what happens in April, when open enrollment has ended and everyone who has purchased a plan is clearly covered.

In the meantime, Sheila Lawless offers this advice to patients who have bought plans on the exchange: “If you pay your premium prior to [visiting the doctor], print that out and bring it with you because that will certainly save all a lot of grief.”

This story was produced as part of a collaboration between NPR and Kaiser Health News.

Copyright 2014 Kaiser Health News. To see more, visit

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