Payment problems vex Washington online health exchange

Many first-year problems with Washington’s online health-insurance exchange have yet to be resolved. One particularly nettlesome area involves payments made through the exchange, but officials say they’re working to fix the problems.

Two months after open enrollment closed, Washington’s online health-insurance exchange still faces complaints from consumers and organizations about how it is performing in its first year.

Many of the complaints involve the enrollment process and, in particular, the system under which enrollees make payments to insurers, payments that are handled by the exchange.

One group, the Association of Washington Healthcare Plans (AWHP), complained recently that an estimated 15 percent of enrollees — up to 25,000 people — may have had problems resulting in service or claims payment delays.

Cristina Rancourt, 55, and her family are among that 15 percent. The Rancourts, who live in Kirkland, thought they had insurance since they finished the application procedure in December. But about three weeks ago, when they were denied coverage for a prescription, they called their insurer, Premera.

“Premera said we didn’t have coverage because they hadn’t received a payment since February,” Rancourt said. “We’ve been getting bills and we’ve been paying them. Somebody has been cashing the checks.”

According to Bethany Frey, spokeswoman for the Washington Health Benefit Exchange, which operates the Washington Healthplanfinder online exchange, the Rancourts are indeed enrolled.

“Several tech issues have been going on with their account related to payment files … and we worked with Deloitte to deploy some fixes over the weekend,” Frey said. “If there are issues with the payment files, a carrier may subsequently not know that the customer has paid. We are working with Premera to allow their prescriptions to be accessed while we reconcile the payment issues with their account.” (Deloitte is the outside contractor that helped develop Healthplanfinder.)

The AWHP, an alliance of health-maintenance organizations and health-service contractors, outlined what it believes are the problems in a letter to the Washington Health Benefit Exchange. The letter listed five main problems it said the exchange needs to address:

• Delays in sending premium-payment files to insurers.

• Incomplete premium-payment files sent to insurers.

• Failure to transmit termination files.

• Problems with invoices, including inaccurate or missing invoices.

• Improper dual eligibility for some users for exchange plans and Medicaid.

The association called on the exchange to come up with a detailed road map describing how and when all the identified defects will be resolved before 2015 open enrollment, which begins in November.

The letter, signed by the association’s executive director, Sydney Smith Zvara, also called on the exchange to forgo implementation of new features or system projects until the problems are resolved.

“It is not appropriate to continue to confuse members and make it difficult for them to navigate the system and access the coverage for which they have paid,” Zvara wrote.

Frey said the issues covered in the letter have been discussed at the exchange’s public board meetings. “We have an internal team working directly with Deloitte to identify and resolve invoicing and payment issues as quickly as possible,” Frey said.

The payment problems aren’t the exchange’s only challenges, of course. At the end of February, Healthplanfinder had 15,000 “stuck” applications resulting from processing problems, missing information or issues involving tax returns.

The exchange said it has been making progress in resolving these cases and that, despite the flood of new applications before enrollment closed at the end of March, the number of stuck applications was down to 12,300 last week.

Another gauge of complaints comes from consumers who addressed their problems to the Office of the Insurance Commissioner (OIC). According to a report obtained by The Seattle Times, the OIC received 170 individual complaints between Jan. 1 and May 7, only about one-tenth of 1 percent of the more than 164,000 individuals enrolled in private health plans through the exchange.

Not surprisingly, most of the complaints were received in March and April, leading up to and just after the March 31 enrollment deadline.

A review of the complaints shows the majority of issues fell into one of two categories, and reflect the areas of concern specified in the AWHP letter.

In many cases, consumers reported their plans had been canceled or changed, but the consumers claim they didn’t make the change.

According to Michael Marchand, the exchange’s communications director, problems with the exchange’s software resulted in such changes, but he says those glitches have been fixed. In other cases, users may not have finished enrolling after making a change.

“If they didn’t finalize it, it would have canceled them out of that enrollment, even though to the user it would’ve appeared that they correctly enrolled,” Marchand said.

Also, some users whose income level placed them close to Medicaid eligibility may have been moved into or out of that program. According to Marchand, on April 1 the federal qualifications for Medicaid changed, so some people previously Medicaid-eligible became eligible instead for an exchange plan with a tax credit.

The most common complaint came from consumers whose insurers tell them they haven’t received payments from the exchange.

Marchand acknowledges that in the first months after the exchange launched there were glitches in processing payments. But he said record-processing has improved since then.

Insurers aren’t totally convinced. AWHP’s Zvara said the exchange has told insurers that a number of system fixes have been implemented. “We have, however, not yet seen meaningful improvement to date,” Zvara wrote in the May 21 letter to the exchange.

Said Marchand: “I have to admit we are as frustrated as consumers are. We’re doing all this for the first time. And in our view, if one person is having an issue with their plan being changed or canceled that’s one person too many.”

Patrick Marshall is a freelance technology writer in Seattle. This story was produced through a partnership with Kaiser Health News, an editorially independent part of the Kaiser Family Foundation.

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