It Is Not Insurance, It Just Looks Like It: ‘We Make Them Self-Pay’
Growing numbers of patients are handing over what looks like valid insurance cards to registrars; in reality, they have no coverage at all. These patients pay monthly premiums to healthcare sharing ministries.
“These plans definitely are a source of heartburn for us,” says Pete Kraus, CHAM, CPAR, FHAM, business analyst for revenue cycle operations at Emory Healthcare in Atlanta.
The authors of a recent report looked at five healthcare sharing ministries, all of which include disclaimers stating that they are not insurance.1 “But people believe they have insurance. They go into the hospital saying, ‘Here’s my card,’” says JoAnn Volk, a co-author of the report.
Some members expect the plan to pay hospitals directly, just like insurance. However, patients submit bills to the plan and potentially are reimbursed for some portion of it — or not, depending on the circumstances. “At the very least, it confuses consumers,” says Volk, a research professor at the Georgetown University Center on Health Insurance Reforms. Some plans stipulate that members must exhaust all other possibilities before submitting expenses to be considered for reimbursement. In some cases, plans are very specific: Patients must prove they were denied financial assistance from the hospital. In many ways, the plans closely resemble health insurance. “They have a safe harbor that says they are exempt from any insurance regulations, as long as they follow the letter of the law,” Volk notes.
Some plan operators state that they have a network of affiliated providers who give steep discounts to members. “Even if there is a disclaimer stating it’s not insurance, every other part of it looks like insurance,” Volk says. Plans use terms like “provider network” and “schedule of benefits.” They offer bronze, silver, and gold plans, the same terminology used to categorize plans purchased on the Health Insurance Marketplace. The plans stop short of calling payments made by members “premiums,” referring to them instead as a “monthly share.”
“They will not call it a premium, but it sure feels like a premium,” Volk adds. Healthcare sharing ministries work out fine for some patients who submit bills, comply with the requirements, and receive some amount of reimbursement. “But many people are being aggressively marketed with radio ads during open enrollment,” Volk explains. If someone cannot afford premiums, certain insurance brokers will offer the plans as a more affordable option. A high-deductible plan, while not ideal, still is insurance, Volk says. This gives the member certain rights. “You can appeal a denial. You can go to the insurance commissioner and say they are not following the contract,” she says. “None of that applies to healthcare sharing ministries.”
Wes Lindsey, senior director of marketing and communications at Medi-Share Christian Care Ministry, one of the five healthcare sharing ministries analyzed in the report, says, “We go to great lengths to explain the differences between Medi-Share and health insurance. The term ‘healthcare sharing ministry’ is reflective of numerous organizations, very much in the same way that the term ‘insurance’ is. Medi-Share is one organization, among many. Healthcare sharing ministries are a unique solution to more than a million Americans who need an affordable alternative. Healthcare sharing ministries are not for everyone, but for our members who appreciate this community approach to healthcare and the providers who serve them, it works.”
For patient access, healthcare sharing ministries cause many issues. The first one is figuring out that the card presented is not really insurance. “Our clinic in particular has struggled to come up with a reliable protocol to manage these plans prior to when the patient presents,” Kraus laments.
Staff conduct precertification during preadmission calls, which means they do not always see the patient’s insurance card. “Our precert vendor sometimes is unable to inform us what sort of coverage a patient has,” Kraus explains.
Certain plans are not healthcare sharing ministries, but they are not really legitimate insurance plans, either. “They may technically be valid, but cover very little. We often don’t find this out until the claim is denied,” Kraus reports.
Other times, the patient’s insurance is fraudulent. Hospital policy states that in these cases, the patients are considered to be uninsured. “This is upsetting to the patient,” Kraus says. Payment plans, financial assistance, and charity are some possible options. “It’s no different from dealing with the underinsured population in general,” Kraus says.
The problem becomes more complicated if coverage is not verified beforehand for some reason. This can happen because the system is down, or if a registrar simply neglects to do it. Registration is decentralized, so not all registrars answer to patient access. “Access tries to develop good working relations with such departments, with varying degrees of success,” Kraus offers.
The hospital’s insurance verification vendor has not been particularly helpful. Patient access submits insurance data during the preadmit process. Despite this, problematic plans are not flagged until after the claim is submitted. One obstacle is that some plans with next-to-no coverage are underwritten by known insurance carriers. “There is no reason in principle why they can’t supply us with the benefits. But it’s never that simple,” Kraus says.
All this means that denials occur after the claim is filed. “The business office then has to deal with these accounts as they are identified in the collections process,” Kraus explains.
Mary Rutan Hospital in Bellefontaine, OH, is seeing a surge of patients who are part of healthcare sharing ministries. “We are struggling to find solutions,” says David Kelly, CHFP, MHSA, director of the revenue cycle. The patients come in thinking they have valid insurance. When told otherwise by registrars, they blame the messenger. “These plans are a big cause, in my opinion, of the increase in surprise bills in the news. But they aren’t really being addressed by anyone,” Kelly offers.
Most of the time, the problem is identified on the front end. Then, patients are treated as self-pay. For the hospital, it is the lesser of two evils. “Accepting the ‘insurance’ often causes the plan to claim that you’ve agreed to their rates as reimbursement in full, which of course, without a contract, we don’t agree to,” Kelly notes.
The patient, newly classified as uninsured, is connected to a financial counselor. “It can definitely lead to surprise bills if we don’t catch it on the front end and make changes on the back end,” Kelly says. Sometimes, the problem is not caught quickly enough. Patients receive surprise bills, some of which go uncollected. “But, fortunately, we offer very generous payment plans,” Kelly adds. “These prevent a lot of significant bad debt situations from arising.”
REFERENCE
- Volk J, Curran E, Giovannelli J. Health care sharing ministries: What are the risks to consumers and insurance markets? The Commonwealth Fund, Aug. 8, 2018. Available at: http://bit.ly/2XccwOJ. Accessed June 28, 2019.
Growing numbers of patients are handing over what looks like valid insurance cards to registrars; in reality, they have no coverage at all. These patients pay monthly premiums to healthcare sharing ministries. Some members expect the plan to pay hospitals directly, just like insurance. However, patients submit bills to the plan and potentially are reimbursed for some portion of it — or not, depending on the circumstances.
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