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HR 1070: Passing a bill is not for the faint of heart

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The current political climate on the Hill requires persistence if we want to make change.

The Affordable Care Act (ACA) seeks to improve access to colorectal cancer screening by waiving coinsurance*, copays, and deductibles for many colorectal cancer screening tests. Screening tests include colonoscopies, sigmoidoscopies and fecal occult blood tests (FOBT). This sounds simple in theory, but implementation is proving more challenging than expected.

Take a few minutes today to read through why changing policy takes time, and the importance of your representatives’ support when it comes to laws that directly impact costs associated with colon and rectal cancer screening.


Changing Policy Takes Persistence

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Photo source: Washington Post

Fight Colorectal Cancer is actively working on policy changes that will reduce barriers for patients seeking screening services, including fixing some kinks in application of current law.

Currently, there are 6,352 bills and resolutions before the U.S.Congress, of which about 5 percent will become law. (Source)

What does this mean for us?

Changing policy takes persistence. The average time for a bill to become law averages 3-5 years depending on the complexity of the legislation.

But that hasn’t stopped us from working with others and introducing new laws to fix problems we see. One being HR 1070.

 

 


The Cost Sharing Oversight

The ACA has generated unprecedented public debate and discussion over health care vs. “sick care.” Generally speaking, the American public supports policies that increase access to preventive services, including screenings.

In May 2012, the American Gastroenterological Association (AGA), American Society for Gastrointestinal Endoscopy (ASGE), the American Cancer Society-Cancer Action Network (ACS CAN), National Colorectal Cancer Roundtable (NCCRT) and Fight Colorectal Cancer met with officials from Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) to discuss this problem that Medicare patients face when receiving a screening colonoscopy.

As a coalition, we lobbied for a correction for both private payers and those covered by Medicare. HHS has the authority to make changes to commercial payers because it has broad regulatory authority. For this particular issue, CMS argued it does not have the same broad authority to make changes to Medicare. We didn’t see immediate response or improvement. Dr. Howard K. Koh, MD, MPH, the current Assistant Secretary for Health for the U.S. Department of Health and Human Services encouraged us to maintain our momentum. At the NCCRT annual meeting in November 2013, Dr. Koh said,

“Keep pushing and talking about this important issue. This is not easy work. It takes time, but you are doing the right thing by working together to fix this.”

In the case of screening colonoscopies, the Obama Administration provided guidance to private insurers on application of cost-sharing requirements for private insurers (this excludes Medicare) by releasing an FAQ on Feb. 20, 2013, stating that if a screening colonoscopy is performed and a polyp is found and removed during the screening, then an insurer cannot impose cost-sharing since polyp removal is “an integral part of a colonoscopy.”

Despite an administrative clarification issued on February 20, 2013 that prohibits commercial insurers from imposing cost-sharing when a screening colonoscopy involves polyp removal, the clarifying guidance has been met with varied interpretations by commercial insurers, and we are even seeing variations in interpretation by state***.

Additionally, incorrect coding practices by physicians have contributed to situations where cost sharing is being inappropriately imposed on patients. Physicians and the medical community require further education on appropriate billing and coding practices based on the guidance provided. At the end of the day, it boils down to how the medical’s billing process defines and differentiates screening and diagnostic procedures.

So our first step:  address Medicare.


HR 1070: Reducing Barriers to Colorectal Cancer Screening

charlie-dent-hr-1070We support this legislation that addresses the oversight in Medicare’s cost sharing and reduces barriers to screening.

Many seniors are waking up from colonoscopies to an unexpected $100-$300 bill for a polyp removal (polypectomy). A polypectomy is standard practice during a screening colonoscopy, but the removal of the polyp(s) triggers a change in the classification of the service provided from a “screening” service to a “therapeutic” or “diagnostic” service under Medicare’s billing codes.

Knowing that a patient may wake up to an unexpected bill can create a significant barrier to fixed-income seniors who should have this potential life-saving screening. Congressman Charlie Dent (R-PA) introduced H.R. 1070 to amend current law so Medicare beneficiaries will not be liable for coinsurance when a polyp is removed during a screening colonoscopy.

“This is a glitch in the law that needs to be changed,” said Rep. Dent. “We want more people to get colonoscopies. It is a life-saving screening procedure.”

This legislative fix will have a major impact on colorectal cancer screening, since almost 38 percent of U.S. adults age 50 and older have never been screened. In the case of colorectal cancer screening, it is impossible to know whether a patient will have a polyp before the screening takes place. Patients should not be penalized for seeking screening when polyps are removed during the procedure. It’s time for change, and we’re ready to fight for the long haul.

Now is our time—we can make a difference.

A domino effect: CMS is a leader in the insurance industry

Medicare is the largest healthcare insurer in the United States, with more than 42 million beneficiaries, making it an industry leader in coverage policies and standards. CMS contracts with numerous healthcare entities and thousands of providers and practices across the country to administer the Medicare program.

In short, Medicare sets the standard for how billing is processed.

We know this oversight in current Medicare law has resulted in confusion and frustration for our seniors and for many who are privately insured. With the help of CMS, Medicare can lead the way toward standard, uniform cost-sharing practices for screening colonoscopies among private payers.

It is imperative that CMS’s leadership and members of Congress understand this issue. The intent of the law is to encourage screening; however, when patients receive unexpected bills after undergoing a screening colonoscopy, it is seen as a penalty and disincentive.

Why does this require a bill?

CMS stated in the 2011 Medicare Physician Fee Schedule Final Rule** that legislative action is necessary to waive the beneficiary coinsurance for colorectal cancer screenings. So our FIRST step to passing corrective legislation is to generate as many cosponsors of H.R. 1070 as possible.

We’ve been gaining co-sponsors since 2012, and this year we will continue. Passing a bill is NOT for the faint of heart, but advocacy is a long journey that keeps your fight alive.

Help us!

In 2014, you can be a part of the solution! ASK your representative to cosponsor HR 1070, or thank him/her for already doing so. To find contact information for your representative, go here.

If you need ideas on how to reach out, review how to be an eAdvocate. 

To see the full list of cosponsors and a detailed description of the bill, visit https://www.govtrack.us/congress/bills/113/hr1070


Notes…

* Coinsurance is the term used by health insurance companies to refer to the amount that you are required to pay for a medical claim, apart from any co-payments or deductible.

**The Medicare Physician Fee Schedule Final Rule is an annual update to payment and payment policies for Medicare Part B services.

***For more on private insurance practices, Fight Colorectal Cancer joined the National Colorectal Cancer Roundtable, the American Cancer Society, The Kaiser Family Foundation, and stakeholders across the country to further examine this emerging cost barrier to colorectal cancer screening, in a report entitled, “COVERAGE OF COLONOSCOPIES UNDER THE AFFORDABLE CARE ACT’S PREVENTION BENEFIT,” published in Sept. 2012.

****Here’s the exact language provided by the government in their FAQ guidance document to private insurers:

Q5: If a colonoscopy is scheduled and performed as a screening procedure pursuant to the USPSTF recommendation, is it permissible for a plan or issuer to impose cost-sharing for the cost of a polyp removal during the colonoscopy? No. Based on clinical practice and comments received from the American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and the Society for Gastroenterology Nurses and Associates, polyp removal is an integral part of a colonoscopy. Accordingly, the plan or issuer may not impose cost-sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure. On the other hand, a plan or issuer may impose cost-sharing for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.

ADDITIONAL RESOURCES TO BETTER UNDERSTAND THIS ISSUE

What about Medicaid?

The latest report from NCCRT, Coverage of Medicaid Preventive Services for Adults – A National Review, was the basis of an article published in Health Affairs this past summer. The study intends to provide a better understanding of Medicaid coverage of preventive services for adults in the current state Medicaid programs and inform state policy makers as they consider the level of preventive benefits and services to offer should they expand Medicaid in 2014.

You may access the full report and the article abstract here.

For more on Federal and state colorectal cancer screening legislation go here. 

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