No Colonoscopy Cost Sharing

HHS says patients shouldn’t pay for polyp removal during screen-ings.

By G.J. Verhovshek, MA, CPC

The U.S. Department of Health & Human Services (HHS) has instructed insurers not to impose cost sharing on those patients who have polyps removed as a result of a covered screening colonoscopy. The guidance is a potential boon to patients, and should make life easier for providers who perform such screenings.

Good Intentions, Mixed Results

Under the Affordable Care Act, most insurers are required to provide coverage, in full, for a variety of preventive services, including “evidenced-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force (USPSTF) with respect to the individual involved.” Among those services are “screenings for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults beginning at age 50 years and continuing until age 75 years.”

Put more simply, as part of healthcare reform, the majority of insurers must cover screening colonoscopies without cost sharing to qualified plan participants.

For instance, suppose an asymptomatic 65-year-old patient arrives at his physician’s office for a “free” screening colo-noscopy. The physician examines the patient and gives him a clean bill of health. The patient leaves the office satisfied with no need to pay anything out-of-pocket.

Now, let’s alter the scenario slightly. The same asymptomatic patient arrives for the same expected service, except this time the physician finds a polyp (this happens on average in one out of five screenings). Both the patient and physician are present and prepped, so it makes sense for the physician to remove the polyp, which he does.

But wait, many insurers have argued. Because the physician removed a polyp, this is no longer a screening procedure, it’s a diagnostic procedure. And because healthcare reform doesn’t prohibit cost sharing for a diagnostic colonoscopy, the patient’s standard deductible and co-pay provisions apply.

Therefore, our patient—who met all the requirements for a “free” screening and expected that’s what he’d re-ceive—potentially finds himself owing hundreds of dollars in deductibles and co-payments. Yes, the exam caught a problem early on—that’s good—but the patient still feels like the victim of a “bait and switch” scam. On top of it all, the provider practice is responsible to collect payment from this now confused and angry customer.

HHS Weighs In

In late February, as part of a series of articles entitled “FAQs about Affordable Care Act Implementation,” HHS posted to its website “Limitations on Cost-Sharing under the Affordable Care Act,” which clarified that patients should not be subject to cost sharing when a screening exam uncovers a polyp:

Q5: If a colonoscopy is scheduled and performed as a screening procedure pursuant to the USPSTF rec-ommendation, 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 Gastroenter-ology 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. (Source)

Unfortunately, the HHS guidance does not have the force of law; however, patient advocates are hopeful that insurers will take notice and change their policies accordingly. The likely result would be happier patients, as well as fewer headaches for offices that offer colonoscopy screening services. Keep an eye on your payers’ policies, and keep your fingers crossed.


G.J. Verhovshek, MA, CPC, is managing editor at AAPC.


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