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Things you never expected from ACA

June 22, 2015
by Jill Sederstrom
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The Affordable Care Act (ACA) mandates changes in healthcare delivery, however, some secondary, ripple effects of ACA have turned out to be even more challenging at the practical level. Today’s providers are scrambling to retool.

Widespread impact on traditional medical providers has been well documented and examined, but ACA impact on the behavioral healthcare community is a bit murkier. Meanwhile, behavioral providers are often left with questions as they try to navigate a new world of healthcare.

1. Complex payment models

As healthcare prepares to shift away from fee-for-service, a host of alternative reimbursement models based on ACA provisions are gaining momentum  across the country. In fact, a national think tank, Catalyst for Payment Reform, measured the types of models being used in healthcare today and concludes that as much as 40 percent of today’s reimbursement is designed to be value-based instead of fee-for-service.

According to Patrick Gauthier, director of AHP Healthcare Solutions, such alternative forms of payment could be the biggest challenge facing mental health and substance abuse treatment providers.

“On the one hand, ‘reimbursement reform,’ which is sort of an umbrella term for these new models, is very exciting,” Gauthier says. “On the other hand, it represents a lot of risk and a lot of challenges.” 

One of the largest challenges, he says, is making sure providers have the business savvy to be able to evaluate the various models, interpret them for real world application and recognize where their specific risks are. Many of the new payment models will expect the provider to share in the financial risk. Providers must know in detail what is going to be required of them and what infrastructure will be necessary to adopt the models.

“If you estimate your costs and revenue projections wrong, you’ll be underwater very, very quickly,” Gauthier says.

He also recommends providers accrue legal, financial and managed care competencies in house or hire outside assistance. Once the strategic team is in place, Gauthier says, providers need to carefully look at each opportunity because no two arrangements are the same. Each is influenced by geographic location, covered services, patient population characteristics and data reporting requirements.

“Some people might read about something in Boston and try to apply the same principles in Denver, and find it won’t work,” he says.

Behavioral health providers are often second to the table—after ambulatory medical and acute hospital providers—which means behavioral health must be vigilant about the possibility of commercial payers trying to apply cookie-cutter models to behavioral health. How the new payment schemes will translate from the medical disciplines to the behavioral disciplines remains to be seen.

When configuring agreements that include financial risks, Gauthier says it’s essential to make sure providers are clear about what particular sets of accounting principles are being used and that they’ve developed accurate cost per unit figures.

Other contract essentials include: outlining covered diagnoses, covered providers, covered procedures and services, covered supplies and prescription drugs, and covered sites of service. For example, if a patient goes to the emergency department, a provider caring for him or her regularly might be assigned responsibility for failing to prevent the acute event, depending on diagnosis. And that responsibility could result in reduced payment in a risk-based contract.

2. More eligibility checks

As more people get access to health insurance, the administrative burden for providers is also growing. For example, more programs are navigating patient-eligibility checks. In order to ensure reimbursement, the provider must be sure the patient actually has valid coverage or risk a claim denial. While that seems like a straightforward task, ACA provisions add some complexity.

“There are grace periods if a client enrolls in [a new ACA health plan] and then doesn’t pay their premium,” says Elizabeth Reed, LMSW, project manager of the Behavioral Health Affordable Care Act Initiative (BHACA) in Houston.  BHACA is a joint project of the Network of Behavioral Health Providers and Mental Health America of Greater Houston, created to help providers implement ACA.

Premium payment is necessary for the client to be officially covered by the health plan policy. According to ACA guidance, there is a grace period if the client fails to pay up, but that leaves providers in limbo, not knowing if the client is truly covered and if the claims will be paid during that time. Reed says office staff might need to make additional phone calls and do additional follow-up eligibility checks after the initial patient encounter.

When coverage changes midstream, it can take providers by surprise. According to Marion Coleman, executive director of the Network of Behavioral Health Providers in Houston, a number of providers have reported checking a patient’s eligibility initially, and then later after billing for subsequent appointments, realizing the patient is no longer covered. Payers have suggested checking a patient’s eligibility before each appointment, but that adds a considerable administrative burden.

“What the CEOs are telling us is they just don’t have the staff to check every single time; that’s just not a realistic expectation,” Coleman says.