Detailing Inconsistencies On Who Has to Pay for Their Polyps

Colon polyps being removed


The Kaiser Family Foundation, working with the American Cancer Society and the National Colorectal Cancer Round Table, today released results of its investigation into the problem of patients being billed unexpectedly for costs of colonoscopies initiated at routine screening tests. Fight Colorectal Cancer was one of the organizations that contributed to the report.

One way the new federal Affordable Care Act (ACA) aims to reduce medical spending is to improve cost-effective screening that prevents or detects diseases before they become complicated and expensive to treat.

But consumer complaints reveal that, for screening colonoscopies in particular, consumers are getting unexpected bills when insurers decide their colonoscopies were no longer “screening” procedures. Instead of providing full coverage required by the ACA federal law with no cost-sharing, patients may be charged either copayments or deductibles.

Colorectal cancer is a poster-child for showing how better screening saves lives and dollars. It’s the third most common cancer and second most common cause of death from cancer in men and women combined in the U.S., with more than 143,000 people diagnosed—and almost 52,000 deaths—every single year. Treatment, especially for advanced colorectal cancer, can be very high: An estimated $300,000 or more per year for an advanced case. Experts estimate that various payers (Medicare, insurance companies, medical providers and individuals) spend about $12.2 billion treating colorectal cancer each year.

The good news: Regular screening can diagnose colorectal cancer early—when it is much less expensive to treat and may even be curable. And unlike most other cancers, removing polyps during screening can actually totally prevent the cancer from developing.

The bad news: One in three adults aged 50 and 75 are not up-to-date with recommended colorectal cancer screening (2010 figures).

Cost of screening
There are three different ways to screen for colorectal cancer: an inexpensive annual stool test (fecal occult blood test) yearly; or a sigmoidoscopy to view the lower colon every 5 years; or the most expensive, the colonoscopy to view the entire colon every 10 years.

It’s true that colonoscopy can cost from $1,000 to $2,000 or more—still a bargain compared to the cost of one case of colorectal cancer undetected until its later stages.

But federal planners intentionally included colorectal cancer as one of the conditions whose screening is supposed to be fully covered—with no cost to the patient—as part of the Affordable Care Act.

Billing surprises
But partly because there are several methods of colorectal cancer screening, and, ironically, partly because screening can actually become a preventive procedure, some consumers are getting ugly surprise bills in the mail. And if consumers think they could be billed (for example, $200 or more under an 80/20 insurance plan) for such a screening, they’ll likely avoid the cost and the life-saving screening.

The Kaiser Family Foundation has published a white paper to illuminate the issue and offer solutions to the problem. Researchers interviewed state health insurance regulators, state consumer-assistance program directors, insurance company medical directors, medical experts, insurance billing experts, and patients.

They found wide variations in whether—and how—insurers and providers define, interpret, and bill pay for screening colonoscopies, especially in three situations:

  1. When a polyp is detected and removed during a screening colonoscopy;
  2. When a colonoscopy is performed as part of a two-step screening process following a positive stool blood test; and
  3. When the individual at increased risk has earlier or more frequent screening.

Also, patients may not realize that the federal ACA preventive services coverage requirement doesn’t yet apply to self-insured plans or “grandfathered” plans in existence before March 2010.

Interviews revealed in those three situations, insurers may or may not bill the patient as if the colonoscopy was a diagnostic or “treatment” procedure rather than a screening test.

A common problem
In about half of all screening colonoscopies, polyps are removed—causing some insurers (including Medicare) to reclassify the procedure as treatment versus screening. Doctors can’t tell during the colonoscopy which polyps might be precancerous; studies show about half of polyps removed are adenomatous (precancerous), while the others are benign.
When a colonoscopy is the required followup for a possibly abnormal stool test or sigmoidoscopy, some insurers bill it as a diagnostic test—even though other insurers feel it is a second step in screening.

And the definition of screening gets even fuzzier in people at higher risk for colorectal cancer, either because of their family history or because they’ve previously had adenomatous (precancerous) polyps removed. Those people are supposed to be screened more often—but many insurers define those colonscopies as surveillance rather than screening.

It depends where you live
Worse yet, billing practices vary from state-to-state: Connecticut says screening colonoscopies cause the most complaints; other states say they receive few complaints. “In general, state regulators appear to be looking to the federal government for direction,” the Kaiser authors wrote. “In Georgia, for example, regulators said they are awaiting further guidance in order to move ahead on this issue. Other state regulators … also indicated they have reached out to the Department of Heath and Human Services (HHS) for further guidance and do not want to ‘get ahead of HHS’ on this matter.”

A case example
Sarah, who lives in New Hampshire, has a history of colon polyps and receives routine colonoscopies every 5 years. At her most recent screening, she confirmed with her provider that the screening would be covered at no charge to her under the new provisions of the ACA. He said he thought it would, but had heard of patients being charged if polyps were removed. So Sarah asked her insurer, who said colonoscopies were fully covered even if polyps were removed. Sarah went ahead with the procedure. A few weeks later, her insurance statement indicated her deductible applied, and Sarah owed $1,300. She also received a bill for over $600.00 from the anesthesiologist. Sarah learned her screening had been coded as “diagnostic” based on her personal history, and was therefore billable. She notified her insurer that this was a routine “surveillance” colonoscopy and should be fully covered under the ACA preventive benefit. Eventually she was able to get all charges removed but wonders if other patients would be as informed and capable of self-advocating.

What to do?
The Kaiser authors described several possible courses of action:

  • The federal government could define guidelines about whether or when cost-sharing should be waived when polyps are removed; when a colonoscopy is following up to positive FOBT; and, for colorectal, breast, and other cancer screening, whether cost-sharing should be waived for higher-risk patients getting more frequent tests.
  • Officials and/or payers could clarify consistent billing and coding methods.
  • Consumer feedback could be monitored to see whether new policies are followed.

You can help
Earlier this year, H.R. 4120, the ‘‘Removing Barriers to Colorectal Cancer Screening Act of 2012,” was introduced in the U.S. House of Representatives by Rep. Charlie Dent (R-PA).

H.R. 4120 would waive a Medicare beneficiary’s coinsurance for a colorectal cancer screening colonoscopy, regardless of whether a polyp or tissue is removed during the test. H.R. 4120 has bipartisan support, but your help is needed to push the number even higher. Please take a minute to contact your Representative today.


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