Pandemic turbulence easing on medical groups’ payer mix

An intensely competitive job market and low unemployment typically would suggest a strong economy and robust commercial insurance rates for workers.

According to a March 29, 2022, MGMA Stat poll, less than half (47%) of medical groups report that their payer mix has seen an increase in uninsured or self-pay patients in the past year, compared to the majority (53%) that saw no such increase.
The poll had 351 responses.

Among medical groups experiencing an increase in the share of self-pay and uninsured patients in their payer mix, practice leaders cited the following trends in payer mix during the COVID-19 pandemic:

• An increase in Medicaid patients as commercial coverage declined
• Continued increases in high-deductible health plans and higher out-of-pocket expenses
• A higher share of ACA health exchange plans
• Patients with lapses in coverage as they changed jobs in the past two years.

Payer mix trends among practices that did not see an increase in self-pay and uninsured patients in the past year echoed their colleagues regarding the increased prevalence of out-of-pocket spending as well as the growing share of Medicaid patients. Additionally, these practices reported:

• Significant increases in managed care and health exchange plans
• Slower claims processing and payments among different payer types
• More time spent on claim edits and appeals.

Recent Centers for Medicare & Medicaid Services (CMS) National Center for Health Statistics data point to a slight improvement in the overall rate of uninsured Americans in January through June 2021 compared to 2020, as the rate of uninsured Americans dropped from 9.7% to 9.6% (31.6 million to 31.1 million). Early results for the full-year study of 2021 suggest that rate may have dropped to 8.9% by the start of 2022.

Tracking coverage changes across the pandemic

The early months of the COVID-19 pandemic produced radical changes in medical groups’ payer mix, as unprecedented job losses shifted healthcare payments away from employment-based commercial insurance plans. A July 2020 MGMA Stat poll found that almost two-thirds of all payer mix change was associated with growth in Medicaid (41%) and self-pay (24%), and another 13% tied to Medicare as a growing share of overall payer mix.

These trends continued into 2021. A U.S. Census Bureau report from September 2021 revealed that:

• Annual Medicaid enrollment between February 2020 and January 2021 rose from 34 million to 40.2 million among adults.
• Medicaid and Children’s Health Insurance Program (CHIP) enrollment rose from 35 million to 38.3 million for ages 18 and under in the same period.

However, the same report only found a 1 percentage point drop in private coverage from early 2019 to early 2021. Additionally, it’s important to note that the U.S. government report only considers a person uninsured if they have no coverage at any time during a year, and those who lost coverage in 2020 are not included in that rate.

Big changes for uninsured COVID-19 care

On March 22, the Health Resources & Services Administration (HRSA) program for reimbursing healthcare providers and facilities for testing, treatment and vaccine administration for uninsured patients stopped accepting claims for testing and treatment due to lack of funds. Vaccination claims are set to be cut off at the end of the day April 5.

As a result, some smaller pharmacies and clinics — especially those in areas with higher uninsured rates — are weighing their ability to continue offering COVID-19 shots.

The exhaustion of federal funding comes after $15 billion in pandemic relief was stripped from the March omnibus spending package passed by Congress and signed into law March 15.

Other considerations for uninsured/self-pay patients

The No Surprises Act (P.L. 116-260), passed by Congress in 2020, established new requirements for providers to issue cost estimate information to uninsured or self-pay patients. These new requirements took effect Jan. 1, 2022.

The uninsured or self-pay good faith estimate (GFE) requirements instruct providers to issue a discounted cash price cost estimate for expected medical services upon request or upon scheduling services for an uninsured or self-pay patient. And while the intent of the new requirements is to increase price transparency, there are significant burdens on group practices that have already resulted.

A Jan. 25, 2022, MGMA Stat poll identified medical group practices’ top concerns with implementing the new GFE requirements. Of those who responded to the poll, 44% identified the disruptions in workflow that will result from the new GFE requirements as the greatest challenge with providing cost estimate information to uninsured or self-pay patients.

• MGMA members can access exclusive video of the GovChat Live webinar on uninsured and self-pay GFE requirements.
• An updated MGMA Government Affairs resource on implementing the No Surprises Act is available for member download.

Action steps for managing payer mix changes

As noted in the July 2020 MGMA Stat data story, it’s vital to focus on front office and billing staff to ensure extra care is taken to confirm the insurance and eligibility for patients. It is also a good time to review practice procedures and policies on upfront copay or coinsurance collections, payment plans, self-pay discounts and charity care as applicable.

Even with low unemployment, patients who might be struggling with higher costs of living due to inflation and surging prices for housing and gasoline may request more flexibility on paying their balance, especially if they are covered under a high-deductible plan. Ongoing communication and transparency with patients before, during and after their visits on any balances that are the patients’ responsibility will improve the overall practice collections and patient experience.

Significant changes in payer mix will alter a practice’s collection ratio and may result in a reduction of net revenue. Practices with a significant shift away from commercial insurance to Medicare or Medicaid generally will experience an overall decrease in revenue. Administrators should be regularly tracking multiple key performance indicators (KPIs), including payer mix as compared to the historical norm. This allows a practice to trend the changes and determine the financial ramifications for future payments.

There are a handful of steps practices can take to respond to these payer mix changes:

• Administrators should be regularly tracking multiple key performance indicators (KPIs), including payer mix, as compared to the historical norm. This allows a practice to trend the changes and determine the financial ramifications for future payments.
• If your practice is experiencing a drop in net revenue from your payer mix, it may be time to evaluate and renegotiate rates on your commercial contracts.
• You may need to adjust your office hours or see more patients per day to achieve the same level of revenue based on your new practice payer mix.
• Using benchmarking data, tracking KPIs, evaluating payer contracts, increasing access and maximizing A/R collections are more important during periods of decreased patient volumes.

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Additional resources  

• MGMA COVID-19 Recovery Center — The latest updates, tools and resources to help your practice navigate through the pandemic.  
• MGMA Stat: Measuring the Impact of the COVID-19 Pandemic — Find all our COVID-19 data stories going back to the start of the pandemic.  
• MGMA COVID-19 Federal Assistance and Advocacy Center — Follow the latest regulatory and legislative updates regarding the pandemic from MGMA Government Affairs.