We all know that one of the goals of the Affordable Care Act (ACA) is to provide healthcare coverage to all Americans. Whether it’s through Medicaid Expansion or through Health Insurance Exchanges/Marketplaces, everyone should be covered, right?

Well, with the exception of those who will choose to take the tax penalty instead, this should be the case. So why are we still not seeing the number of enrollees in the health Insurance exchanges/marketplaces anywhere near the predicted number of Americans that would be eligible for plans being offered on the exchanges/marketplaces?

As of the end of February 2014, only 4 Million of the eligible 47.5 million uninsured consumers have enrolled. So what’s going on with the remaining 43.5 million consumers?

Medicaid expansion will pick up some of the uninsured and there are some that have chosen to buy qualifying plans outside of the exchanges/marketplaces, probably even fewer still became eligible for employer sponsored plans. This still leaves a huge population of uninsured consumers out there.

Even with all the publicity around the Federal Healthcare Exchange/Marketplace, there are still people out there that don’t understand or realize that this pertains to them. CMS continues to bump up their efforts to get the word out, I recently saw signs on a highway exit ramp here in Georgia advertising Healthcare.gov. With less than a month to go for open enrollment, they probably should have invested in big billboards instead of the small yard signs I encountered!

The truth of the matter is that Providers need to be prepared to deal with the uninsured in a new way. You will need to know how and where to guide patients that may present as being Uninsured. If you are a provider that deals with a high number of Uninsured patients, you may want to consider becoming a Certified Application Counselor (CAC) organization . The CAC certification will allow you to assist patients in selecting and enrolling in Exchange/Marketplace plans. You will also need to consider processes for assisting patients that may be eligible for Medicaid coverage. CMS has published lots of educational and informational materials that can be provided to patients. It’s not as easy to find as it probably should be so here is a good place to get started: http://www.hrsa.gov/affordablecareact/toolkit.html.

For providers that have not instituted a focused effort on financially pre-screening patients, the time has come to do so! The Newly Insured population that is signing up for plans available on the Exchanges/Marketplaces are likely to have deductibles, co-pays and co-insurance that they may not clearly understand. Experienced insured consumers continue to see their deductibles and co-insurance amounts grow larger each year.  It’s important to have methods in place to at least identify the patient’s financial responsibility and, ideally, collect it prior to services being provided.

Nextgen Healthcare has several tools available to assist providers in this new world. If you are not already using RTS, this is one way to proactively obtain the patient’s financial responsibility prior to services being provided. RTS enables you to run insurance eligibility requests directly from your Appointment List. If you have a high volume of walk-in patients, RTS can also be utilized at the time the patient presents.

With this evolving population of newly insured patients, there is going to be a transition between the time the insured enrolls with a plan and the time they receive notification of coverage. Generally, the coverage will be retroactive back to the first day of the month of enrollment, likewise with most Medicaid plans.  It’s important to stay on top of these types of “pending coverage” accounts and make sure that once the coverage is identified, it’s updated on the patient’s encounter.

In a lot of cases, these “pending coverage” cases slip through the cracks and don’t become evident until the patient receives a statement and calls to update or, unfortunately, collection activity becomes eminent or active. Nextgen Healthcare has a new utility to help identify situations such as this prior to the patient having to become involved, NextGen Eligibility Self Pay (ESP).

ESP will check for coverage with Medicaid, Medicare, any secondary insurance or third party liability insurance that may be on file with Medicare, and the plans that are available for a given state on the Exchange/Marketplace. The results are returned as an Encounter Note in NextGen PM, and tasks are created for those encounters where coverage is found. ESP will also work with scheduled appointments so that you can identify any lack of coverage before a patient presents.