State Insurance Exchanges: Hospital IT's Next Challenge

Ken Terry | InformationWeek | September 26, 2013

As state insurance exchanges take hold, hospital IT departments must figure out how to keep up with patients' insurance eligibility, health status and benefits in fluid environment.

The launch of the state insurance exchanges on Oct. 1 is not top of mind for hospital CIOs, who are dealing with everything from Meaningful Use and ICD-10 to ACOs and value-based reimbursement. Nevertheless, the exchanges and the accompanying Medicaid expansion in some states will affect the IT departments of hospitals and health systems in a number of ways, say consultants and an official of the American Hospital Association (AHA).
First, the prospective coverage of millions of uninsured Americans will require changes to the revenue cycle management (RCM) systems that hospitals use for billing and collections. Hospitals already check eligibility electronically, but the advent of the exchanges will substantially increase the number of plans for which they must do this, noted Doug Hires, executive vice president of Santa Rosa Consulting.

A large portion of the newly insured will be comprised of the working poor, who earn too much to qualify for Medicaid but don't have employer-provided insurance. In states that plan to expand Medicaid to individuals earning up to 133% of the federal poverty level, that will be the dividing line between those who are eligible for Medicaid and those who can get government subsidies to buy insurance on the exchanges. [...]