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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  • EE Smith

    “…or maybe they never really thought about the details”

    They had to pass the bill to find out what was in it.

    And nothing about Obamacare can be changed, ever. That’s what they keep saying, that what they passed was L-A-W LAW! and apparently once the Democrats push through a L-A-W LAW! it cannot ever be changed. Ever.

    I hope when this dog’s breakfast of a law (L-A-W LAW!) comes into full effect, people remember that not one single Republican voted for it. This is the Democrats’ baby, 100%, and to them is due all the glory. The AMA deserve their share of glory too, for having been such enthusiastic propagandists for it.

    • lynneb

      First, this “Democrat’s baby” was taken directly from a Republican playbook of several years earlier (y’all have a very short memory). Second, Joseph Caovoted for it, and he’s Republican. Third, if Congresscritters had not caved to/been swayed by lobbying of insurance companies whose first and foremost interest is in protecting their profit, maybe you would have had a better chance of joining the rest of the civilised world in having decent healthcare.

      If you are going to insist on running a healthcare system as a for-profit consumer market, like buying a TV set, instead of the infrastructure issue that it actually is, like basic education and roads and defense, then yes, you’re going to end up with a fragmented system that works poorly.

      • May Wright

        Cao voted for the draft “Affordable Health Care for America Act” (H.R. 3962). He joined the rest of the GOP in voting against the final version, the “Patient Protection and Affordable Care Act”.

        Nice try though!

      • ninguem

        If there’s anybody with a short memory it’s you.

        I don’t care who’s playbook it came from. The Republican Party is no more monolithic than any other. There were objections to the plan from many corners of the Party.

        The fact remains that the plan was brought to a vote by the Democrats, voted on by the Democrats, rammed through by the Democrats.

        Not one single Republican vote. Not one.

        It is 100% the Democrats plan. They own it. No blame to the Republicans, no blame to the insurance companies, 100% of the blame to the people……and party…..that voted for it, over the objections of the opposition and large swaths of the population, if not the majority.

        • Judgeforyourself37

          The ACA type of plan has been voiced by Republicans twice. The first time it didn’t fly, but was in response to what the Republicans called, HillaryCare in1993. Then, more recently it was implemented in Massachusetts, by, no other than Mitt Romney, when he was governor of MA. Oh, he disavowed it in the 2012 election. It works rather well in MA and like the ACA, is supplemented by Medicare, Mass Health supplements the Commonwealth Care in MA, for those who cannot pay the entire premium.

          • EE Smith

            No Republican has ever run for Federal office with the promise of implementing an “ACA type of plan”. Federally-enforced and managed universal healthcare like Obama’s ACA has never been on the GOP platform, ever.

          • GT

            It’s cute, how now that Obamacare is proving itself to be every bit the disaster Republicans warned it would, those same Democrats who pushed it through now want to disown it.

          • ninguem

            If it were working so well, you would think the Democrats would be trying to take all the credit.

            Amazing how much effort they spend trying to convince people that a plan that received zero Republican votes in Congress, was a Republican plan.

  • ErnieG

    This is what happens when third party payers, who not only have every reason to deny payment, but have no ethical professional obligation (unlike MD, nurses do). You get knaves and rogues skimming off providers. There is no way a health provider is going to do a colonoscopy or well visit, and not do something when an abnormality is found. It is not medically accepted to do a screening colo first, find the polyp without polypectomy, then have the patient come back for another colo. BUT in the mind of the third party rogue who nickels and dimes the masses, it is no problem. There is a very strong ethical reason to reduce the influence of insurances in medical decision making, a concept very foreign to ACP, AMA, and medicare. Instead, it sounds cruel to be against “insuring everyone”, when instead “insuring everyone” means placing the yokes of knaves on our necks.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Welcome to the consumerization of medicine. This is marketing 101

    FREE* all-you-can-eat chicken wings**!!

    * With purchase of 2 adult drinks. Offer good Monday to Thursday 4pm to 6pm. Cannot be combined with other offers. Additional charges may apply.
    ** Other snack foods may be substituted

    • Deceased MD

      Brilliant.That example is spot on. I think one of the worst parts of all of this, to doctors and pts alike is that it is made to be so very devaluing to all.

    • May Wright

      It was just a marketing ploy. Obama knew he could suck in low-information voters by promising them “free stuff” … and sadly, it worked. Meanwhile, his cronies in big insurance and corpmed are laughing all the way to the bank. Just like fellow big-government enthusiast Bush’s cronies in the military-industrial complex did when *he* was in power.

      I don’t think America will ever have a President who isn’t owned in some way by special interests. This is why I would prefer a government with as little power as possible. The fewer things politicians control, the less it matters who controls the politicians.

  • heartdoc345

    Can you post a link to that Ezekial Emmmanuel article?

  • ninguem

    Did you expect anything else from this administration?

  • buzzkillerjsmith

    And the winner for the best comment on the thread is familydoc!

  • Claire

    How long until we start seeing Groupon deals or yelp deals for colonoscopies? I am not being facetious here. I am totally serious. I give it a year max. I am already getting them for dental cleanings.

  • dontdoitagain

    What is the point of having a “screening” if they are not going to correct the problem easily at that time? Do a virtual. It costs less and is a lot safer. (I read that 70,000 people a year die from their routine colonoscopies) Or even better, just do the stool sample which is really cheap.

  • johnfembup

    Are you saying that you think your physician and the other service providers who assisted with your treatment should have been paid even less they were?

    Also, I believe the government’s definition of preventive care, and the manner in which reimbursement for preventive care is determined, are the same as insurance companies have used for many years. ACA simply copied their rules. I’m not suggesting this as any justification for them. In fact, the reverse – - because it further underscores your comment about the lack of thought and creativity in ACA.

    I think it also underscores the fact that ACA is really about “insurance” and not about “health care”. So in my opinion, it has no real chance of improving “health care” or reducing “health care” costs for anyone. (And so far, it’s not doing much of a job in reducing health insurance costs either.)

    • fatherhash

      i don’t think he was saying they should’ve been paid less, just that his portion should not have been what it was since it was a screening colonoscopy(but essentially got converted to diagnostic colonoscopy since a polyp was found).

      totally agree that ACA is more about health insurance than healthcare…and also that this colonoscopy rule was simply copied from existing policy. for example, when my father had his scope about 15yrs ago, i called the insurance to get the pricing ahead of time and they said the same thing….free(for him) if screening scope, but if they find a polyp, it automatically gets converted to diagnostic scope and gets charged accordingly.

  • Retired IM Doc

    The extra charge for the polyp removal is not for all plans under the ACA. Please see http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs12.html and http://www.dol.gov/ebsa/faqs/faq-aca12.html to see how confusing it really is.

  • PM

    If the claim was submitted with a primary diagnosis of preventive care (V code) and secondary diagnosis as the polyp, the claim then should have been processed by Medicare as preventive and the secondary insurance (supplement policy) should also have processed using the ‘V’ code of preventive services??

  • doc99

    You have to pass the bill so you can find out what’s in it.

  • Mika

    “Obamacare covers screening colonoscopies”
    No, it doesn’t. Obamacare mandates that insurers provide “free” screening colonoscopies. That’s one of the reasons everyone’s health insurance premiums are going up – there ain’t no such thing as a free lunch (or a free screening colonoscopy).

    Obamacare could just as easily have mandated that insurers provide “free” screening colonoscopies AND polyp removal, but then insurers would have had to hike their rates even more.

    And the cohort we desperately need to suck in, in order to subsidize the erst of us — the young and healthy — are not going to stand for having to pay $1500/month so that their richer elders can get “free” screening colonoscopies AND polyp removals and whatever else the boomers want them to subsidize.

  • Yehuda

    So many ACA opponents in this thread (including myself). How did this disastrous monstrosity get passed with so many in the medical field opposing it? How did Obama even get re-elected?
    Or are you all just “Johnny-Come-Latelys” who’ve supported Obamacare all along until you started noticing the consequences?
    I’m very curious.

  • bill10526

    President Obama wisely tasked Senator Bcaukus, a democrat, and Senator Grassley, a republican, to draft the heath care legislation. High ups in the Republican party decided to scuttle the effort and Senator Grassley droped out. He could have modulated the crazy Democrats with their preventative medicine nonsense. Shame on Senator Grassley.

    • EE Smith

      We had a Democrat President and a Democrat super-majority in Congress when this law was passed. It’s beyond ridiculous to blame Republicans, when they were the ones pointing out this law’s failings all along.

      • bill10526

        Yiou missed the point. It wasn’t that hard. To get enough Democrats, the prevention nuts and feminists had to be placated. Our country would have been better served by modulating the program instead of putting all effort into destroying it.

        • EE Smith

          Republicans were a minority in the House and a minority in the Senate. They had no way to influence what this Democrat President with his Democrat-controlled Senate and Democrat-controlled House were determined to push through.

  • southerndoc1

    Complete red herring. Medicare and many private insurers covered screening colonoscopy prior to Obamacare; Obamacare only eliminated any co-pay for the procedure. The screening versus therapeutic coding problem has been around for a long time. But accuracy in criticizing Obamacare seems to be irrelevant . . .

  • GT

    She should contact the White House then. So far, every “Obamacare Success Story” they’ve trotted out has turned out to be a fraud.

  • Teresa Caruthers

    I know I read that this concept and practice was deemed illegal and that removing a polyp is also to be seen as prevention; that the change in coding is not to be done. I was relieved to read this. I am sorry now to hear that this is not so!

  • Jessica Yaron

    Many insurance companies have the same “catch” and have had them for several years.

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