The Affordable Care Act mandates private health insurers cover preventive services without patient cost-sharing; however, how a colonoscopy is classified – screening or diagnostic–can create bills for patients.
Doctors hope that by making it easier to undergo screening colonoscopie or flexible sigmoidoscopy exams, cancer mortality rates will decline.
What Is Covered?
Under the Affordable Care Act (ACA), most private health plans provide colonoscopies without cost sharing for screening purposes under most private plans. Colonoscopy has received an A rating from the U.S. Preventive Services Task Force as one of its recommended procedures; yet when it comes to billing it can become complex.
Depending on their symptoms or family history of polyps, screening tests may not qualify as screening and could incur coinsurance and deductible charges. Furthermore, certain providers code their procedures differently when precancerous polyps are removed – potentially increasing patient out-of-pocket expenses. Situations such as this one typically require weeks-long negotiations between patient, insurer or provider and patient to find an acceptable resolution. Melville’s case was no exception: she felt wrongly billed. She wonders how many other patients may be experiencing similar challenges due to confusing insurance rules, and advises practices to inform patients of the possibility that they could incur costs for a colonoscopy procedure. The American Gastroenterological Association advises practices to inform patients they may incur charges in relation to undergoing colonoscopies.
What Is Not Covered?
Though the Affordable Care Act mandates that patients should not incur costs associated with colonoscopies classified as screening, insurers’ billing and coding practices for screening colonoscopies vary depending on insurer. When polyps are removed during screening colonoscopies, this procedure could become diagnostic, subjecting patients to coinsurance or deductible fees or copayments; while some insurers waive all cost sharing for colorectal cancer screening procedures irrespective of whether polyps are removed during them.
Other insurers disagree; for example, one large health insurer’s medical director stated: “We don’t mind if we remove polyps; it is still screening colonoscopy.
National Colorectal Cancer Screening Network’s survey of insured adults revealed that many are surprised to receive unexpected screening bills, which can discourage people from getting preventive tests recommended by doctors. A significant portion of this problem arises in grandfathered plans that existed prior to Affordable Care Act’s passage (known as grandfathered plans) because those policies have differing coverage requirements than the ACA – often forcing patients with precancerous polyps to pay coinsurance charges when getting colonoscopies and other preventive services such as colonoscopies or preventive services when precancerous polyps are found and require coinsurance when colonoscopies or preventive services are rendered when needed.
What Should I Do?
The Affordable Care Act (ACA) mandates that insurance companies cover screening colonoscopies as preventative health benefits; however, definitions of screening colonoscopies vary based on insurance plan and provider; some plans require patients to pay a deductible or coinsurance payment if their screening colonoscopy reveals precancerous polyps or masses during their procedure.
Colonoscopie is an effective, quick, safe, and pain-free method of inspecting the colon and rectal areas. A colonoscopy allows healthcare providers to detect polyps as well as cancer in early stages for early removal and detection.
Medical experts advise all adults over 45 to undergo routine screening starting at age 45, or sooner if recommended by your physician. A fecal immunochemical test (FIT) or colonoscopy is the best way to detect adenomas, precancerous cells and colorectal cancer – according to the Centers for Disease Control (CDC), regular colorectal screening saves lives by finding them early and effectively treating them while simultaneously decreasing one’s risk.
What Can I Do?
Laws surrounding health insurance vary by state and insurer, making it harder for consumers to receive preventive services recommended by the U.S. Preventive Services Task Force.
Colonoscopie is one such test, and according to the Affordable Care Act (ACA), private insurers and Medicare must cover its cost after receiving positive results on a FOBT, stool DNA lab test or FIT. Unfortunately, providers’ coding practices for such exams can lead them to unexpected out-of-pocket expenses such as co-pays or deductibles that affect consumers unwittingly.
Interviews conducted with four large health insurers’ medical directors revealed that four do not impose cost-sharing for colonoscopies following positive FOBT, FIT or stool DNA lab tests; three other insurers do. Of those that impose cost sharing for colonoscopies following these positive screening tests – four said no impose cost sharing while three others did; those charging could discourage people from receiving regular screening tests regularly, according to an expert medical opinion; inconsistent coding by doctors compounded this issue further; consumers should discuss with their physician the best time and place to have their colonoscopy performed.
