The recent release of a report by Consumer Representatives to the National Association of Insurance Commissioners (NAIC) sheds light on compliance gaps in Affordable Care Act (ACA) preventive services coverage and cost-sharing protections. This report is not only a comprehensive assessment but also a valuable set of recommendations for state insurance regulators to enhance the enforcement of vital consumer safeguards.
The spotlight is on an often overlooked aspect of preventive services access: complex and seemingly arbitrary plan policies for claims processing and payment. The intricacies of these policies determine the combination of procedure and diagnostic codes that providers must use to get reimbursed and flag claims as preventive. However, mismatches between codes can result in patients being charged for services that should be free.
The ACA holds preventive services and their coverage as paramount. More than 150 million people benefit from its provisions. Notably, studies have demonstrated improved health outcomes and increased utilization when preventive services are accessed without cost sharing. These provisions, however, face challenges from litigation aimed at removing them.
The report draws attention to the inconsistency in coverage guidance documents across different plans, which influences providers’ understanding of coding and billing. Variability can lead to miscategorization and billing errors, which adversely affect patient access to free services. While state laws reinforce these protections, limited oversight results in arbitrary variations across plans, with little adherence to clinical best practices.
The key issue lies in the claims adjudication process. Federal or state regulator oversight in this complex process is minimal, giving plans considerable discretion. This lack of control leads to inconsistency and even confusion regarding the coding process. The report exemplifies the variation in publicly posted guidance documents and their content among different plans, impacting services such as smoking cessation and HIV prevention.
Kentucky’s experience demonstrates the challenges providers face due to varying coding requirements. The state’s effort to understand how plans adjudicate preventive services revealed that insurers rarely use the same procedural and diagnostic codes. This inconsistency contributes to higher rates of denials and inappropriate cost-sharing charges.
Regulators need to take action to improve access to zero-cost preventive services. States can request claims data from insurers, following Kentucky’s example, and review compliance. Furthermore, regulators should enforce clearer appeals processes for providers to rectify mis-adjudicated claims. Standardizing billing and coding guidance for preventive services, similar to their claims processing, can streamline compliance efforts.
Until these opaque and arbitrary payment policies are addressed, consumers may continue to face unexpected bills rather than the cost-sharing-free prevention the ACA promises. Regulators must take proactive steps to ensure that the essence of the ACA’s preventive services provisions translates into tangible benefits for consumers.
Source: https://www.healthaffairs.org/
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