Health insurance exchange enrollments mean changes to patient populations, utilization and reimbursement

Despite hopes for high enrollment through the health-insurance exchanges (HIEs) of the Patient Protection and Affordable Care Act (PPACA), the numbers are well below forecast levels as the March 31 enrollment deadline approaches. Many experts don’t anticipate that the enrollment will approach the original goal of 7 million. Estimates have been downscaled to 6 million, based largely on website woes. How realistic are the new figures, though, and where are the opportunities and risks for radiology?

The potential shift of uninsured patient populations into commercial or Medicaid coverage could be an opportunity for radiologists. Many observers anticipate a surge in imaging utilization as this uninsured group begins accessing new health-care benefits.

Sarah Mountford, client services manager for Zotec Partners, says, “Early predictions indicated we would see a jump in utilization, but we haven’t seen that yet because of low enrollments in the plans, thus far.” She says it’s too early to know how these new patient populations will affect providers’ financial interests, but if what we’re seeing so far is any indication, it’s going to mean a lot less, in terms of revenues. She says, “It remains to be seen what the final demographics will be. Radiologists should be prepared, with flexible monitoring systems in place to keep charges and revenue under close surveillance so they can understand how the reimbursements are changing as the patient populations shift.”

Perceived New Patient Populations

A lot of buzz surrounds the so-called new patient populations that the HIEs will create. In reality, and especially after millions of insured individuals’ policies were cancelled last fall, one of the largest patient populations will simply shift from commercial insurance to HIEs—which won’t have an impact on the uninsured population. People who had a plan that worked were told that they could keep them. They didn’t realize that millions of existing policies—their own policies—would no longer be viable because they did not meet the requirements of the PPACA.

“What this means to providers is a large number of patients who were commercially insured in 2013 will shift to HIE plans. In many cases, the plans under the HIEs are reimbursing at Medicaid rates or worse,” Mountford explains. “This shift is likely to be financially detrimental to providers such as radiologists.”

The data detailing HIE enrollments to date were published by the DHHS in January. According to the report,1 60% of enrollees opted for midrange (silver) plans. Mountford says that this number reflects the shift from commercial insurance to HIE plans. “This suggests, by an indication of cost alone, that these patients are not the uninsured poor. Those enrollees would be most likely to opt for a lower-cost plan,” she says.

The Obama Administration predicted that adoption of the PPACA would mean that 33 million people without health insurance would be covered by 2022 (through the HIEs and Medicaid expansion). These data call for two questions, though: Were these people formerly uninsured, or were they insured, but dropped from commercial plans? What will this shift mean for radiologists and other health-care providers?

Bona Fide New Patients

Medicaid expansion under the PPACA is another factor affecting future radiology revenue, utilization, and reimbursement. Under Medicaid expansion, coverage for many low-income adults will be expanded to 138% of the federal poverty level ($15,856 for an individual or $26,951 for a family of three, in 2013). States need to implement Medicaid expansion in 2014 to qualify for expanded federal Medicaid funding.

As of December 2013, 26 states had decided to move forward with Medicaid expansion, while the rest had decided not to expand Medicaid or were still debating their options. Medicaid expansion is critical to insuring many of the 33 million whom the PPACA would cover. Health-care providers in states where Medicaid won’t be expanded will continue to struggle with a high population of uninsured and underinsured patients. 

Radiology is likely to see an increase in utilization in states moving forward with Medicaid expansion, as this represents a true increase in insured patients. That’s the bright side, Mountford notes. The downside comes to imaging groups in the states opting not to expand Medicaid eligibility. In those states, don’t expect to see big changes in utilization. These groups might only see ongoing decreases in reimbursement due to the shifting of patients from standard commercial plans to HIE plans that (in many cases) pay at lower rates.

Providers in Texas, for example, will continue to struggle with the highest percentage of uninsured people in the country (according to the Texas Medical Association), at 33%. Texas represents 12% of the nation’s uninsured individuals, and that population, at present, won’t qualify for Medicaid expansion. While not benefiting from Medicaid expansion, providers in states not expanding Medicaid also might lose some of their standard commercial population to HIE plans.

Monitoring the Changes

“Every radiology group should have flexible systems for ongoing monitoring of its business,” Mountford says. “It is also critical for it to have a system in place to verify that every exam read is billed. Zotec offers comprehensive billing and reporting tools that provide the ability to reconcile billing and reimbursement, as well as to monitor shifts in payor reimbursements.” The ability to validate that every exam is captured and billed (in addition to the availability of analysis tools to reconcile and audit reimbursement data) is critical to ongoing financial success.

Zotec can demonstrate trends in utilization and reimbursement, as well as changes and shifts in patient populations. Mountford and Taylor Moorehead, Zotec’s partner of operations in the West region, will be reporting on a global sampling of these trends in their upcoming presentation, “Stacking the Deck: Why Radiology Health Care Exchanges Are Like a Giant Game of Jenga.” The session takes place on May 5, at 11:30 am (and again on May 6, at 10:30 am), during the RBMA’s 2014 Radiology Summit in Charlotte, North Carolina.

We can only speculate on the outcome of these changes as we wait for final enrollment data to arrive. It remains to be seen how these new patient populations will affect radiology utilization and reimbursement. Vigilance is key to thriving through the changes. 

Sarah Mountford is a 15-year veteran of healthcare billing, coding and client management. She currently serves as a client service manager in the Midwest region for Zotec Partners. Sarah is a frequent speaker at industry conferences for the Radiology Business Management Association (RBMA) and the Association for Medical Imaging Management (AHRA).

1. Health insurance marketplace: January enrollment report. ASPE Issue Brief. Published January 13, 2014. Accessed February 19, 2014.