As most Americans know by now, colonoscopies are very essential to prevent colon cancer which are used to spot colorectal cancer which will kill about 50,000 Americans this year. After the government changed our health care laws, health insurance plans were now being required to cover most preventative care services such as colonoscopies as a free service with $0 out of pocket for the patient.
In actuality, that has happened perfectly as planned. Where it gets tricky is when doctors find and remove a polyp. In this case, many private insurers and Medicare as well, hit the clients with up to several hundred dollars in costs. They can do this because once a polyp is caught, it is no a longer a preventative measure but a treatment.
The American Cancer Society and other advocacy groups have come out swinging against the charges, claiming that the extra expenses are surprising consumers and patients. These expenses can include deductibles, copayments, and coinsurance. The main offenders include Kaiser Permanente (and these guys are the most surprising as their plans are non profit), Health Net, and even Medicare.
Of course President Obama comes out looking ridiculous in this matter, as the Obamas (including Michelle) have been trying to get support for health care reform by highlighting these free preventative care services. Perhaps highlighting is not a good word though, he has been painting this benefit on the sides of barns across the US.
Colonoscopies are the not only procedures either that can shake the carpet. Other preventative care services have been turning up lesions or lumps that need to be removed which would also thusly change the nature of the visit.
The law is quite straight-forward though. It prohibits health plans from imposing cost sharing for preventive services that were part of a visit to a doctor that was focused on prevention, if the services are not billed separately from the office visit. However, an insurer “may impose cost-sharing requirements for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.”
Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, said the colonoscopy issue illustrates the need for a clarification from administration officials about services such as colonoscopy where physicians provide both preventive and therapeutic care in the same visit. In written comments on the federal regulation last year, his group said physicians must understand how to appropriately code preventive services so that insurers know when to waive the deductible and coinsurance.
The federal health law specifies that insurers must fully cover services that have earned an A or B rating from the U.S. Preventive Services Task Force, plus immunizations recommended by the Centers for Disease Control and Prevention, and preventive care for women and children recommended by the federal Health Resources and Services Administration.
That coverage rule took effect last September. It applies to an estimated 31 million Americans in group health plans this year and 10 million in individual plans, and will cover 88 million by 2013.
To qualify for the free coverage, patients must go to providers in their health plan network.
Colonoscopy is on the U.S. Preventive Services Task Force’s recommended list, with an A rating, for all adults 50 and older. It checks for colorectal cancer, which is preventable with screening and highly treatable if caught early. A National Institutes of Health report last year said cost sharing likely affects people’s willingness to have such screening.
If a patient with no symptoms goes in for a screening colonoscopy and the gastroenterologist finds no pre-cancerous or cancerous polyps, everyone agrees that Medicare and commercial insurers are required to cover the expensive test 100 percent. But when the doctor removes a polyp, some insurers apply charges– meaning the insurer pays less of the bill.
Critics say charging cost-sharing defeats the purpose of the law. Studies show that colonoscopies find a polyp in at least 25 percent of men and 15 percent of women. Thus, many people face financial “post-procedure shock,” according to medical and consumer groups that are lobbying to stop insurers and Medicare from applying cost-sharing in this situation.
“We raised this with insurers and they wouldn’t budge,” said Dr. David Johnson, past president of the American College of Gastroenterology. Since the law took effect, “it’s still an ongoing problem,” he added.
Medicare is waiving the deductible for its beneficiaries but charges patients a copay of $186 plus 20 percent of the doctor’s fee, according to a Medicare spokeswoman. She said there have been few complaints from beneficiaries about the policy.
In addition to Kaiser Permanente and Health Net, Regence BlueShield, which has 3 million enrollees in four Northwest states, initially said it charged members the deductible and coinsurance if a colonoscopy found and removed a polyp. But Regence spokeswoman Rachelle Cunningham subsequently said that was a mistake, there should be no cost sharing charges, and the company was “re-evaluating and re-processing some claims.”
A Health Net spokeswoman said that in an effort to help enrollees understand the situation, her company has trained its customer service staff to better explain colonoscopy coverage. Kaiser Permanente officials said the insurer “strongly supports” the health law’s guarantee of preventive services but when “services extend beyond preventive and require diagnostic or therapeutic services” the cost sharing will apply, depending on the specific plan details. (KHN is not affiliated with Kaiser Permanente.)
Aetna, Cigna, Group Health Cooperative, Humana, United Healthcare and Wellpoint/Anthem all said members pay no cost-sharing when a polyp is found. Assurant everyone’s sweetheart carrier, refused to comment.
