Colonoscopy Coverage Creates Confusion

October 31, 2011 -- For years, doctors have urged patients over the age of 50 to get colonoscopies to check for colorectal cancer, which kills more than 50,000 Americans a year. Their efforts were boosted last year by the federal health care reform law, which requires that key preventive services, including colonoscopies, be provided to patients at no out-of-pocket cost.

But there's a wrinkle in the highly touted benefit. If doctors find and remove a polyp, which can be cancerous, some private insurers and Medicare hit the patient with a surprise: charges that could run several hundred dollars.

That's because once the doctor takes action, the colonoscopy morphs from a preventive test into a treatment procedure.

That happened to Steven Guccione of Austin, Texas, who received a notice from his health insurer, Cigna, saying he owed $591 for a recent screening colonoscopy that found and removed a polyp. He appealed to Cigna, which has a policy of covering 100 percent of costs in such cases. Cigna then reversed itself, waiving the charge.

The situation is causing confusion among doctors and the insurance industry. And it's raising concerns among the American Cancer Society, the American College of Gastroenterology, and other physician and patient advocacy groups that consumers could be unprepared for the extra expenses, which can include deductibles, copayments and coinsurance.

Medicare and at least two large private insurers, Kaiser Permanente, with 8.6 million members across the country, and Health Net, with 2.9 million members in several Western states, are charging the fees. Seven other major insurers said they do not charge enrollees.

Charging fees is "just dumb," said Dr. Virginia Moyer, a pediatrics professor at the Baylor College of Medicine who heads the U.S. Preventive Services Task Force, a panel of primary care experts that evaluates medical screening and preventive care. "We need to be sensible."

Adding to the uncertainty is the high-profile campaign by administration officials -- including President Barack Obama -- to increase support for the health law by highlighting the guarantee of free preventive care.

Other procedures, too

Although colonoscopy is the most obvious example of the confusion, it is not the only one.

Dr. Roland Goertz, president of the American Academy of Family Physicians, said it remains unclear how doctors and insurers are supposed to handle patient cost sharing for preventive checkups that turn up medical findings such as a skin lesion or breast lump needing a biopsy or excision during that visit.

"Then it becomes a therapeutic visit," he said. "Should this be a preventive visit with a modifying code, should it be considered only therapeutic, or should the patient be brought back for the needed care?"

Last July, the administration released regulations for insurers on the preventive care benefits. They prohibit 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."

Clarification needed

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.

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.

Critics say charging cost sharing defeats the law's purpose. 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.

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 few beneficiaries had complained about the policy.

In addition to Kaiser Permanente and Health Net, Regence BlueCross 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."

She also said patients "might need to take an active role in appealing a claim they felt was processed incorrectly to receive the benefits they are entitled to under the law."

Negative biopsy effect

Beyond colonoscopy, there is also confusion about the coverage requirement for other common preventive services, such as mammograms.

Dr. Moyer said she personally has experienced the arbitrariness of how insurers apply cost-sharing rules for preventive services. Several years ago, she received a routine screening mammogram for breast cancer that produced a false positive result.

The mammogram was covered 100 percent, though the negative biopsy was not. More than two years later, she went in for another routine mammogram. Because of her prior false positive test, the insurer deemed it a diagnostic test rather than a screening test and imposed cost sharing.

Now she's due for another mammogram, and she's worried that her new insurer will charge her.

"I don't know if my situation is covered by the new law," she said. "It's continuing to haunt me."

Reprinted courtesy of Kaiser Health News