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Affordable Care Act free screening and cost sharing
Old 03-25-2013, 08:51 PM   #1
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Affordable Care Act free screening and cost sharing

Today the administrator of my health insurance plan told me that should polyps or diverticulitis or any other abnormality be found during "free" colonoscopy preventative screening that I would be responsible for the entire cost of the "free" screening.

I thought this was going against the ACA. From what I can tell there should be no cost sharing for this screening in 2013 but maybe I'm wrong.

Then it makes me wonder if any other preventative screening that turns up problems (mammogram, cholesterol screening etc) would no longer be free if they ended up finding a problem.

Am I nuts or is what I have been told true?

FAQs About Affordable Care Act Implementation Part XII
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.
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Old 03-25-2013, 09:11 PM   #2
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Here's one for you...get a "virtual colonoscopy". You still have to drink a gallon of stuff and get completely "cleaned out", but since they just inflate your colon, there's no instrument in there to remove a polyp. There's arguments about how effective the procedure is, overall, but there's agreement that each test has advantages and disadvantages. I guess they could still see a polyp, so would that mean that you'd have to pay? I don't know. If you go in to get a routine physical, and the doctor sees a mole that turns out to be irregular, does that mean the routine physical is now no longer a preventative (free) examination?
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Old 03-25-2013, 09:16 PM   #3
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When I had my first screening colonoscopy last year, I asked this question to my insurance provider. The response was that everything would be covered as preventive except for the associated testing/labs related to any possible polyps or other issues found during the procedure. When I first asked the question, the customer service rep gave me the same response you received but it was incorrect so I asked to speak to someone up the line. Since I had no issues (polyps), I did not find out how they actually would have handled things.
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Old 03-25-2013, 09:52 PM   #4
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I think I'll call back and see if I get the same answer. If I do I'll ask to move up the food chain.

If they end up saying all would be covered I'm going to get that in writing.

I'd have the virtual but the worst part from what I hear is the prep. I sure wouldn't want to do that twice should they find a lil bump hiding up my arse.
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Old 03-25-2013, 10:05 PM   #5
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If they end up saying all would be covered I'm going to get that in writing.
I think this is a good idea - when I spoke to the supervisor, I had them send an email for documentation in case there was an issue at billing time.
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Old 03-26-2013, 04:49 AM   #6
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I think you would be covered for the preventative exam even if they found polyps. This was recently changed. However, if a polyp is found or some other abnormality, you are no longer preventative but diagnostic for future exams. In this case, if your insurance is like mine, you will pay for the next exam - doctor, hospital, etc. Providing an editorial comment, once a potential problem is found, wouldn't you think the insurance companies would encourage regular visits so you are diagnosed early with a problem.
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Old 03-26-2013, 05:46 AM   #7
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The specific rule about not charging for polyp removal was announced earlier this year, and it is effective beginning next January 1. Some insurance plans stopped charging for anything related to colonoscopy procedures a year ago, while others continue to interpret it in the most narrow way possible.

Note, I'm not sure about the Jan 1 date for grandfathered plans but will look for a link I recall from earlier in the year.

Edit to add: the rule was clarified with the Feb release of final rules for essential health benefits. See here http://www.healthcare.gov/news/facts...11202012a.html
It does not apply to grandfathered plans. Here is a useful FAQ http://www.kaiserhealthnews.org/stor...eferrer=search
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Old 03-26-2013, 10:23 AM   #8
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That's what I like about this board -- learn something new every day.

So, I just called my provider and got the news. I have a high deductible plan with HSA. The colonoscopy is covered without any payment on my part. But if they find a polyp, it will cost me. She implied it would just be the polyp and lab, not the original colonoscopy. Right now, I don't have a lot of choice in the matter, so if they backed in the full cost, I'd worry about it then. But, it sounded like they don't do that, but who knows?

Additionally, the plan is grandfathered and they have no plans to change this next year since they don't have to.

In other words, I just lost my excuse to wait another year for this procedure.
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Old 03-26-2013, 11:09 AM   #9
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When DW got her first procedure they used an out of network anesthesiologist. This was before PPACA regs. The deductible was $1K for the colonoscopy, plus another $1.25K for the out of network guy. Separate deductibles.

Between the hospital and different doctors offices it was like a carousel - moving round all the time, going nowhere. Of course, there was no choice and I paid.
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Old 03-26-2013, 02:53 PM   #10
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Just a few comments from a health care "consumer", tax-payer, and colonoscopy survivor:

Forgive the semantic quibble (nothing implied other than what I say): "Free" is an inaccurate word when applied to any service (medical or otherwise). "Covered" is a better, more accurate term. I would accept "included" as well. But "free" sounds like no one has to pay for it. I think we all agree that since someone gets paid to do it, someone has (or will) actually pay for it. End of my quibbling rant - until the next time someone says "free." in relation to medical care

More importantly, while I can't confirm the payment issues "stirred" up by this discussion, I submit that polyp discovery and removal is probably the most cost effective, efficient, successful, life-extending procedure one could ever hope for. Colon Cancer kills 50,000 Americans/year and IIRC is the second leading cause of cancer death (behind:) lung cancer. Colonoscopy, properly scheduled (7 to 10 years for "healthy" patients) and performed, supposedly catches 90% of such pre-cancers and virtually insures no cancers will occur at the treated sites. So, while I see the irony of turning "free" (oooooppps!!) screening into insurance-paid (with some OOP/Co-Pay) I submit that such a "twist" of the Affordable Care Act should not prevent anyone from receiving screening.

Virtual vs. the "full monte" colonoscopy seems a no brainer to me (but, then, I have been accused of having no brain). As mentioned, the "prep" is the only real discomfort any more. My last procedure, I was completely "gone". I remember bits and pieces of my first two, and though a bit disquieting at times, they were not uncomfortable. SO, my "suggestion" is to get the "real deal" and let them take out any polyps while they have you more or less already preped and unconscious. It's only once in 10 years or so. Sorry if I sound like a cheerleader for colonoscopy, but I still have friends who would not be here without it. YMMV
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Old 03-26-2013, 04:09 PM   #11
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Quote:
Originally Posted by Koolau View Post
Just a few comments from a health care "consumer", tax-payer, and colonoscopy survivor:

Forgive the semantic quibble (nothing implied other than what I say): "Free" is an inaccurate word when applied to any service (medical or otherwise). "Covered" is a better, more accurate term. I would accept "included" as well. But "free" sounds like no one has to pay for it. I think we all agree that since someone gets paid to do it, someone has (or will) actually pay for it. End of my quibbling rant - until the next time someone says "free." in relation to medical care

More importantly, while I can't confirm the payment issues "stirred" up by this discussion, I submit that polyp discovery and removal is probably the most cost effective, efficient, successful, life-extending procedure one could ever hope for. Colon Cancer kills 50,000 Americans/year and IIRC is the second leading cause of cancer death (behind:) lung cancer. Colonoscopy, properly scheduled (7 to 10 years for "healthy" patients) and performed, supposedly catches 90% of such pre-cancers and virtually insures no cancers will occur at the treated sites. So, while I see the irony of turning "free" (oooooppps!!) screening into insurance-paid (with some OOP/Co-Pay) I submit that such a "twist" of the Affordable Care Act should not prevent anyone from receiving screening.

Virtual vs. the "full monte" colonoscopy seems a no brainer to me (but, then, I have been accused of having no brain). As mentioned, the "prep" is the only real discomfort any more. My last procedure, I was completely "gone". I remember bits and pieces of my first two, and though a bit disquieting at times, they were not uncomfortable. SO, my "suggestion" is to get the "real deal" and let them take out any polyps while they have you more or less already preped and unconscious. It's only once in 10 years or so. Sorry if I sound like a cheerleader for colonoscopy, but I still have friends who would not be here without it. YMMV
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Old 03-26-2013, 04:22 PM   #12
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... Sorry if I sound like a cheerleader for colonoscopy, but I still have friends who would not be here without it. YMMV
All reasonable points in my opinion until the end: You shouldn't apologize for being a colonoscopy cheerleader.

I had an otherwise very healthy uncle die from colon cancer. His last days were one of the most disturbing things I have ever witnessed; this was made even sadder since it could have likely been prevented by this simple procedure.
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Old 03-26-2013, 07:36 PM   #13
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+1,000,000 on the benefits of C-scopes. Small periodic price to pay for potentially life-saving procedure.
And the prep ain't THAT bad. Just need a comfy toilet seat, a good book (or 3), and plenty of TP
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Old 03-26-2013, 09:00 PM   #14
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After getting through the debacle of my over funded HSA bologna I'll put the screening colonoscopy at the top of my list of things to do.

I also thought the requirement to not pass on cost sharing if they find something might be a requirement starting in 2014 but I'm pretty sure it isn't.

My health plan is not grandfathered. I would have no problem if they wanted me to cost share in the polyp removal but to totally wash their hands of the entire cost of the colonoscopy is plain stupid. Makes me wonder if they would not cover the mammogram fee if they found cancer or a cyst or a third nipple? LOL What about diabetes or cholesterol screening? What about any of the other preventative screenings?

It's pretty disgusting since our CEO has Obama's ear and yet our self insured company does this kind of crap.
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Old 03-26-2013, 11:16 PM   #15
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+1,000,000 on the benefits of C-scopes. Small periodic price to pay for potentially life-saving procedure.
And the prep ain't THAT bad. Just need a comfy toilet seat, a good book (or 3), and plenty of TP
Only heard this, you understand, but some folks think a tube of preparation H isn't a bad idea either.
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Old 03-28-2013, 06:45 AM   #16
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I found the paper I had in mind. A very interesting piece from Kaiser Foundation last September that shows how colonoscopies are treated by different insurance companies Coverage of Colonoscopies Under the Affordable Care Act's Prevention Benefit - Kaiser Family Foundation
Quote:
The Affordable Care Act (ACA) requires private health insurers to cover recommended preventive services such as colonoscopies without any patient cost-sharing. This report finds that confusion over whether colon cancer screenings are preventive care or treatment means patients sometimes receive unexpected bills for the procedure. The report examines cost-sharing practices for colorectal screenings through interviews with experts and officials in the medical and insurance industries.

This report was co-authored by The Kaiser Family Foundation, American Cancer Society, and National Colorectal Cancer Roundtable.
Probably not helpful for this discussion but a good summary about just how confusing it is for consumers, even when regulation has been introduced.
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Old 03-28-2013, 09:11 AM   #17
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Thanks MichaelB. From that I get out of that for my situation is that I should have a good discussion with the office person on proper coding of the procedure before I go under and get whacked by the anesthesia.

A long, long time ago I worked in an office that did billing for doctors, and filed claims with insurance. The coding is crucial, and really easy to mess up.

That said, the article mentions that everyone is so dang confused on this because there is no standard way of coding. One would hope, however, that a practice doing this would be familiar with what works for each insurance company. I know my primary care physician and his office know all the "tricks" of coding. And I don't mean this to say to improperly code which would be fraud, but rather choose the right shade of coding for a procedure. It isn't always cut and dried.
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