The Affordable Care Act and Medical Billers and Coders

By Karen Smiley

The Patient Protection and Affordable Care Act, commonly called Affordable Care Act (ACA) protects individuals who previously didn’t have healthcare coverage but didn’t qualify for Medicaid.

Under the ACA, health plans can no longer deny benefits to children under age 19 for pre‐existing conditions, and young adults under age 26 are allowed to be covered under a parent’s health plan. The ACA also protects individuals from arbitrary decisions by commercial payers, including cancellation of coverage due to an honest mistake, and gives patients the right to request reconsideration if a claim is denied.

Other features include a ban on lifetime coverage limits for new health ­insurance plans and a requirement that insurance companies make unreasonable rate hikes public.

Consumers buy these policies through the Health Insurance Marketplace during open enrollment, which occurs annually from November 15 through February 15 each year. Special enrollment is available outside this period for people who experience life-changing events, such as the birth of a child, the death of a spouse, and others.

As a coder, you need to learn about the plans being offered in your state. Many of the plans function like HMOs, and only providers who have enrolled with the plan are eligible for claim payment. Enrolled in is different from accepts; though your office may accept a plan, the provider may be considered out of network if it isn’t enrolled as a provider in that plan. Also, from a practice management perspective, knowing who your payers are is important when scheduling appointments.

The front office should be educated in the difference between a commercial plan and an ACA plan that is a product of the same company. Usually, the ACA plan card has slightly different filing instructions (it may say that non‐emergency services should be provided within the state, and so forth), and it may not have a group number and/or employer name like commercial cards. When scheduling appointments for consumers with ACA cards, the office may need to probe a bit in order to identify who the actual payer is.

Every patient deserves to be treated; the mantra of the healthcare profession is “It’s always about the patient.” Knowing whether the provider is right for the patient is just good practice management. These individuals are already paying a hefty price for coverage; they shouldn’t be saddled with an unplanned medical bill because the provider was out of network.