The “Ex” Condition

How many times have your claims been denied for having a pre-existing condition? How many times have you re-submitted / appealed those claims? Have they ever been paid? How do you proceed?

On March 23, 2010, President Barack Obama signed the Patient Protection and Affordable Care Act, commonly called the ACA. The legislation is aimed at increasing the affordability and rate of health insurance coverage for Americans, thus reducing the overall cost of health care. The ACA requires insurance companies to cover all applicants within new minimum standards, and offer the same rates regardless of pre-existing conditions or sex.

The Basics
A “pre-existing” condition or pre-ex condition is a health condition that exists before someone applies for or enrolls in a new health insurance policy. Heart ailments, cancer, asthma, and diabetes are several common pre-ex conditions, but it the insurer who generally defines what constitutes a pre-existing condition. Prior to the Affordable Care Act, in the vast majority of States, insurance companies could deny coverage, charge higher premiums, and/or limit benefits to individuals based on pre-existing conditions.

The Stats
According to a new analysis by the Department of Health and Human Services, 50 to 129 million (19 to 50 percent) of non-elderly Americans have some type of pre-existing health condition. Up to one in five non-elderly Americans with a pre-existing condition–25 million individuals–is uninsured.

How ACA Helps:
1. Insurers can no longer limit lifetime coverage to a fixed dollar amount.
2. Insurers can no longer take away coverage because of a mistake on an application.
3. Insurers can no longer deny coverage to a child because of a pre-existing condition.
4. Thousands of uninsured people with pre-existing conditions have enrolled in the temporary high-risk pool program called the Pre-Existing Condition Insurance Plan, which has saved many lives by covering services like chemotherapy.
5. Starting 2014, no denials for pre-ex conditions.

Like it or not, ACA is here to stay. More and more people will have insurance, leading to more patient volume, less effort to obtain patient collectibles, and higher reimbursements.