Sunday, November 19, 2017
Health

Federal ruling clarifies colonoscopy coverage, but patients still wary

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No one looks forward to screening tests for colon and rectal cancers. But under the Affordable Care Act, patients are at least supposed to save on out-of-pocket costs for them. Coverage is not always clear, however, and despite the federal government's clarifications, consumers still have questions.

Under the law, most health plans are required to cover a range of preventive health services without any cost-sharing by patients if the services are recommended by the U.S. Preventive Services Task Force, an independent group of medical experts. (The only exception is for health plans with grandfathered status.)

The task force recommends colorectal cancer screening for most adults starting at age 50. A colonoscopy is the most thorough of the screening tests and is favored by many clinicians. About half the time, polyps are found and removed to determine whether they are cancerous. This removal can create billing problems, says Katie Keith, a research professor at Georgetown University who co-authored a report on screening colonoscopy coverage under the Affordable Care Act.

According to the study, some insurers judged that a colonoscopy with polyp removal was a therapeutic rather than a screening procedure, and billed patients for some or all of the cost, which can reach $2,000 or more.

In February, the Obama administration stated that for people in group and individual health plans, polyp removal during a screening colonoscopy was an integral part of the screening test and should be covered without patient cost-sharing.

People who are at higher risk for colon cancer because of family history or polyps also face a gray area in cost-sharing. In February, the federal government clarified that high-risk patients could qualify for more frequent screening without cost-sharing.

Despite this, some patients have run into snags. Because three polyps were found during a colonoscopy five years ago, Allen Worob, 66, is considered at high risk for colon cancer. His doctor advised to get a follow-up colonoscopy in five years. At first, his insurer told him that the procedure would cost him nothing if no polyps were found but that he'd owe $2,500 if one were.

The New York man was later told that the procedure would be covered without any out-of-pocket charge. But Worob decided to wait for a letter from his insurer spelling that out.

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