By Tom Kisken
Ventura County Star, January 28, 2012
Patients are getting charged as much as $3,000 for screenings they thought would be free under a federal health care reform mandate that promises free preventive care.
Most of the problems revolve around colonoscopies — screenings designed to detect colon and rectal cancers that kill about 52,000 Americans a year.
The procedure has been covered by federal health care reform for men and women 50 and older since September 2010, although many older insurance policies are exempt from the new provision.
Some patients are still receiving bills for deductibles or co-pays when the procedures show an abnormal growth called a polyp that can develop into cancer.
Insurance companies may charge for screenings or tests if patients show symptoms of cancer or are going through a colonoscopy as a follow-up to an earlier diagnosis, said Robert Zirkelbach, spokesman for the trade group. But many insurers consider colonoscopies to be preventive care — and covered — regardless of whether polyps are present, he said. Bills are sent when they aren’t told the nature of the procedure.
“One of the challenges is: How are those procedures being coded by physicians?” he said. “Is it clear that it’s a preventive service?”
Some doctors, however, insist the issue isn’t coding, but rather money and the insurers’ desire for it.
“That is subterfuge,” said Dr. Paul Sanders, a Thousand Oaks gastroenterologist, contending insurers are shifting blame from themselves to physicians. “It’s utter baloney. The insurance companies have quite intentionally blocked any way that anybody could understand what they’re going to, and not going to, pay for.”
Charles Rosen, a Simi Valley insurance broker and president-elect of the California Association of Health Underwriters, tells clients to minimize chances of any billing confusion by not talking to a doctor about any health concerns during a screening exam.
“If you have a pending issue, make another appointment,” he said.
http://www.vcstar.com/news/2012/jan/28/free-preventive-care-can-cost-patients-big-money/
Comment:
By Don McCanne, MD
Colonoscopy is one of several cancer screening tests that are covered 100 percent – no deductibles nor coinsurance are required. What separates out colonoscopy from the other screening tests is that it is frequently converted, on the spot, to a therapeutic procedure when polyps are detected and removed.
Somewhere between the billing office for the physician or outpatient department and the processing of the claim by the insurer, the diagnostic and procedure coding is changed from the free screening test to the therapeutic procedure, subject to cost sharing. The physician blames the insurer, and the insurer blames the physician. But it is the patient who is harmed by being required to pay the out-of-pocket costs of a therapeutic procedure after having been promised a free screening test.
As is typical in our health care financing system that turns decisions over to private insurers (even if only private administrators of Medicare), the president-elect of the California Association of Health Underwriters advises patients to withhold medical information until after they have received their free screening. Only then should they inform their physician about the rectal bleeding or the tenesmus that they have been experiencing. What’s a little fraud if it is only the patient that is committing it?
There are two policy lessons here.
One is that deductibles, co-payments and coinsurance should be eliminated for all appropriate care. Payment issues should not interfere with health care decisions made by the patient with the best advice of the physician. The harm dome by erecting financial barriers to care is potentially far greater than the almost negligible decrease in our national health expenditures that would result from cost sharing (most of which is merely shifted from the insurer to the patient). Obtaining appropriate health care should not result in the assessment of cost sharing penalties or fines.
The second policy lesson is that we need to throw the middleman crooks out. Only that industry would come up with a solution that patients should be instructed to lie to their health care professionals. Not a lie to withhold information? Isn’t the oath for swearing in, “The truth, the whole truth, and nothing but…”? Maybe the whole truth is confidential proprietary information. At least that’s what the insurers keep telling us when we ask for transparency.