Patients charged for screenings they thought were free
Most billing problems revolve around colonoscopies.
Scripps Howard News Service
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.
The year-old provision compels new insurance policies to cover colonoscopies, mammograms, blood pressure screenings, HIV tests and many other procedures aimed at early detection of health problems, with no co-pays or deductibles. But doctors say the requirement — designed to make it easier to get care — may morph into a roadblock because some patients are getting billed when certain preventive procedures reveal growths that could become cancer.
"I think it stinks. The ludicrous thing is the reason you do screening is to find something," said Dr. Jack Rotenberg, a digestive system specialist in Oxnard, Calif., suggesting that charging people when problems are diagnosed is the definition of bait and switch.
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.
When doctors remove a polyp during a colonoscopy, the procedure is often defined as diagnostic and not preventive. That means Medicare and many private insurers ask patients for fees that, depending on policy terms and facility fees for surgery centers, can range from a nominal fee to $3,000.
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 a national trade organization, America's Health Insurance Plans. 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?"
He called on the federal government to hold a hearing on the issue to provide guidance on medical coding and make sure insurers and doctors are on the same page.
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 gastroenterologist in Thousand Oaks, Calif., 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."
Zirkelbach refuted suggestions that insurers are gaming the system, noting his organization predicted issues with medical coding even before the health care reform law began.
And if patients are billed for colonoscopies in which polyps are removed, the patients should talk to the doctor and the insurer, he said.
Representatives of the American Society for Gastrointestinal Endoscopy blame the problems in part on government regulations involving the difference between preventive and diagnostic care. They're pushing Congress for changes that assure colonoscopies are free to patients, regardless of polyps. Efforts also should focus on making sure all doctors explain to patients that they may get billed for colonoscopies, said Laurie Sobel, a senior attorney with the Consumers Union group that works to protect consumers.
Patients also should not be charged for an entire visit but only for the part of a procedure in which a growth is removed, Sobel said.
Charles Rosen, 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.
(Contact Tom Kisken of the Ventura County Star in California at TKisken@vcstar.com