Health Insurance Needs Bills Guaranteeing Transparency, Fair Payment, Says Nurses’ Union

Senate Bill 153 stops health insurers from playing games with payment, ensuring that both nurse practitioners and their clinics are paid the same as doctors. Senate Bill 523 requires insurers to tell providers upon request if a patient has fallen behind in payments, rather than simply denying payments while leaving providers unaware.

The Oregon Nurses Association is supporting a pair of bills designed to protect independent nurse practitioners against unfair practices by the health insurance industry.

The nurses’ union is joined in support by the Oregon Medical Association for the first bill, Senate Bill 523, which fixes a snag in healthcare administration that has resulted from the Affordable Care Act -- people who buy health insurance on the online exchange and fall behind on payments are given a 90-day grace period before they are cut off of their insurance, but insurers may not pay claims and providers are unaware of the patient’s status.

SB 523 creates transparency by requiring the health insurers to inform providers about the delinquency status of their members upon request.

The second bill, Senate Bill 153, seeks to correct bad-faith behavior by a few insurers that have gone back on their agreement to pay nurse practitioners and physician assistants the same as doctors for the same services.

Under the ACA, for the first 30 days after a missed payment, the health insurer must continue to pay claims. For two months after that, however, they can deny claims until their members pay their premiums.

This happens even when an office manager calls the insurance company in advance of an appointment: the administrators are told simply that a patient is insured, since the patient is still technically enrolled for 90 days, even if the insurers will only pay the claims for 30 days after the missed payment.

Polly DeVore, the director of Olive Branch Family Health in Enterprise, drove the 368 miles from northeast Oregon to explain the havoc caused when insurers don’t properly share information with providers. A patient might have a series of treatments of increasing expense, all while a provider believes that person is covered by insurance when, in actuality, they are not.

“We can see when there’s a problem with middle initials, we can see when there’s a problem with date-of-birth, we can’t see when there’s a problem with eligibility,” Devore told the House Health Committee on Wednesday.

Transparency & Responsibility

“It’s important to protect providers for procedures that they do, surgeries that they do, that they ultimately don’t get reimbursed for,” Sen. Tim Knopp, R-Bend, told his colleagues when SB 523 hit the Senate floor last month.

Sarah Baessler of the Oregon Nurses Association said this bill would help providers and patients figure out how to pay for a service, particularly if that person has fallen more than 30 days behind on their premiums.

“Providers can counsel patients about the value of health insurance and explore other alternate programs that may be available to the patient, if their circumstances have changed,” added Courtni Dresser of the Oregon Medical Association. “This not only ensures continuity of care, it takes the burden of potential medical debt off the shoulders of the patient and the provider.”

Baessler said the nurses’ union preferred changing Oregon insurance law to require insurers to pay claims for the full 90-day grace period, and the transparency measures outlined in SB 523 are a compromise.

“It’s really about having mutual responsibility of having providers to ask the questions, to have insurers answer that question in a timely fashion and the patients to pay their insurance premium,” said Sen. Elizabeth Steiner Hayward, D-Portland.

Baessler explained that if insurers don’t tell providers that their patient is more than 30 days late when asked, the insurer will be liable for those claims. “The insurer has to tell the provider that they’re in the grace period,” she said. If a patient ultimately pays their late premiums, the insurer will also pay those claims.

The health insurance industry, including Regence BlueCross BlueShield and PacificSource Health Plans, has asked for a slight amendment that has Knopp’s support. It would require providers to inquire about health insurance status no more than five days before an appointment. Rep. Mitch Greenlick, D-Portland, has asked the insurers and proponents of SB 523 to return to his committee with a consensus amendment.

“I think we’re all in violent agreement that the ACA has a made a bit of a mess around this issue,” said Tom Holt of Regence. “We agree that if we tell a provider that this person is eligible for coverage, if as far as we know they’re current … it does seem reasonable that we be on the hook for that.”

But Holt argued that unethical providers and patients might call the insurance company well before a planned procedure to check on insurance status before the patient stops paying, leaving the insurer on the hook. The five-day limit would prevent this, he said.

Payment Games

Nurses Association lobbyist Jack Dempsey explained that SB 153 is needed because some insurers have done an end-run around the landmark primary care payment parity law passed in 2013 known as House Bill 2902.

Some insurers have demanded that claims be paid to the clinic rather than the individual nurse practitioner. After the clinic staff comply with this request, the health insurers then have underpaid those claims insisting that the pay parity law only applies to individual providers, not clinics.

SB 153 makes clear that if a nurse practitioner or physician assistant is working independently, they need to be paid as well as a physician for the same services, regardless if the billing comes from the clinic or directly from the provider.

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