Obamacare covers screening colonoscopies, with a catch

“An ounce of prevention” we all know is good medicine. An example is colonoscopy. It was time for mine so after some lengthy procrastination I called and set up an appointment which I soon found a perfectly good reason to postpone for a few weeks. A common occurrence. The government wants me (and you) to not procrastinate, at least not because of the cost. The Affordable Care Act (or Obamacare) makes an effort to get more people to get preventive care screening by requiring that there be no deductibles or co-pays for defined screening and prevention services. Sounds good. But there may be a catch, as I soon learned.

The concept and purpose of colonoscopy is to find a polyp and remove it before it turns into cancer. Colon cancers arise from polyps. Polyps are common but only a minority of polyps progress to cancer. But if removed they obviously cannot become colon cancer. Colon cancer is the third most common cancer in men and women in the USA with about 150,000 new cases per year, behind only lung, breast and prostate cancers. And it causes about 50,000 deaths per year. Prevention obviously makes sense.

On my appointed day I arrived at 8:25am having had clear liquids for 24 hours and the effects of a very strong purgative. I was pleased that part was now over. The receptionist seemed like she already had a long day but was nevertheless efficient. By 8:35 I was in a cubicle getting into my procedure gown. Thelma — a wonderful nurse and nurse administrator who had come out of retirement for the intellectual stimulation of working with people — reviewed my pre-completed history and kept up a patter while another nurse deftly inserted an IV.

The senior anesthesiologist came by and then the gastroenterologist, Dr. Kester Crosse. I was whisked off to the procedure room, slipped off to sleep and awoke back in the cubicle. Dr. Crosse came by to say that the procedure went smoothly, that he found a polyp which looked benign and that he had removed it. The pathology report would be back in few days. Another cheery nurse chatted with me and my wife for about fifteen minutes; her medical purpose was to be sure I did not aspirate before fully regaining alertness. When she was satisfied that I was really awake and alert she let me get up and get dressed. We walked out at 9:32am. Most everyone at Digestive Diseases Associates had been friendly, all had been competent and all had done their job effectively. Very efficient and satisfying to me.

The Medicare and Medigap statement came in a few weeks. Dr. Crosse had billed $964. Medicare reduced this to $327.61 as per its formula. In other words, Medicare says a colonoscopy is worth about $328 and it paid its portion of that amount or $262. The doctor is not allowed to “balance bill” me for the rest of what he had originally charged. In order to participate with Medicare he, by contract, has to accept the price Medicare determines.

Since Medicare generally pays about 75% of covered services, the bill next went to my Medigap provider (Carefirst Blue Cross/BlueShield in my case). They did not pay the remainder stating correctly that I have a high deductible policy. So the doctor’s office sent me a bill for the $65.57. I paid it. But what about the new Medicare rule in the ACA/Obamacare that there are to be no co-pays or deductibles for such preventive services?

A check at healthfinder.gov stated that colonoscopy was covered by the ACA and that, “if your doctor finds polyps inside your colon during testing, these growths can be removed before they become cancer.”

I decided to call the doctor’s billing office to check. After the clerk talked to her supervisor she called back to say that I was correct that there was to be no deductible if it was a simple “screening” colonoscopy. But since the doctor had found and removed a polyp it became a therapeutic procedure. Medicare and Medigap (and apparently commercial insurers as well for those under 65) do not recognize this as a preventive screening procedure under the ACA guidelines. Hence I was on the hook for the remaining $65.52.

By chance I was at a breakfast shortly after with a senior person at Blue Cross who confirmed that, yes, this was the rule. I also received a facility charge (nurses, procedure room, equipment, cleaning, etc.) of $695; Medicare reduced that to $391. This left a Medigap portion of $78.15 but again it was my responsibility to pay.

Finally were the anesthesiologist’s bills totaling $975. Medicare reduced that to $150, paid $65 leaving me with a bill of $66. So altogether it cost me just under $250 to have the colonoscopy and the peace of mind that all is in order. Not a bad value.

Admittedly $250 was not a huge amount of money but it strikes me as strange, to say the least, for Medicare rules to say that, since Dr. Crosse removed a polyp while doing the colonoscopy, then it was no longer a screening procedure.

As an aside, I happen to be a big believer in high deductibles. I think that Medicare should be totally changed so that everyone (except the financially challenged) should be required to have a high deductible. That would engage patients into more dialogue with their physicians and lead to better quality at lower cost. I have posted and written an op-ed in the Washington Times about this concept.

But that is not what Congress set into law in the ACA, i.e., Medicare recipients would not pay deductibles for specified preventive screening, including colonoscopy. The whole point and purpose of the colonoscopy is to look for polyps and to remove them if found. It makes little common sense to claim that polyp removal changes the procedure from screening to therapy and therefore not eligible for the no deductible rule.

Admittedly, my argument can be challenged. For example, a screening test for cholesterol would have no deductible but the drug treatment for high cholesterol would of course be another matter. Similarly, if a mammography detects probable breast cancer, the subsequent treatment would not be covered with no deductible. But in the colonoscopy example, the procedure is underway, the doctor finds a polyp and, as part of the process, removes it.

Maybe there should be a separate bill just for the polyp removal part and a deductible for that portion. The facility charge would be the same except for sending the specimen off to pathology and I doubt the anesthesia was any longer or more complicated as a result of the polyp removal.  So most of the deductibles would be eliminated as per Congressional intent.

I wonder what our elected representatives really intended — or maybe they never really thought about the details.

Stephen C. Schimpff is former CEO, University of Maryland Medical Center, chair, advisory committee, Sanovas, Inc., and the author of The Future of Medicine – Megatrends in Healthcare and The Future of Health Care Delivery- Why It Must Change and How It Will Affect You.

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